ML19320B794

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IE Insp Rept 70-1113/80-03 on 800129-30 & 0211-12. Noncompliance Noted:Failure to Properly Label,Provide Placards & Describe in Shipping Documents Shipment of SNM
ML19320B794
Person / Time
Site: 07001113
Issue date: 03/03/1980
From: Clay F, Kahle J, Steele P
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
To:
Shared Package
ML19320B771 List:
References
70-1113-80-03, 70-1113-80-3, NUDOCS 8007150049
Download: ML19320B794 (24)


Text

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UNITED STATES 8

NUCLEAR REGULATORY COMMISSION g)g o

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.m REGION II

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o 101 MARIETTA ST., N.W., SUITE 3100 k

ATLANTA, GEORGIA 30303 o

MAR -41980 Report No. 70-1113/80-3 Licensee: General Electric Company Wilmington, NC 28401 Facility Name: Wilmington Manufacturing Department License No. SNM-1097 Inspectors:

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/he P. W.'Steele Da'te Signed k, X %,

a/Au E. L. Clay

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Date Si ned

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Date ' Signed Approving Section Chief:

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Kahle, Acting Section Chief ITate' Signed Sa guards Branch Date of Inspection: January 29-30 and February 11-12, 1980 Areas Inspected: This special announced inspection involved 22 inspector-hours on site in the areas of material control and transportation.

Results:

In the two areas inspected, three apparent items of noncompliance were found (Infraction - Failure to maintain current knowledge of the location of all SNM (80-03-01); Severity Level III - Failure to properly label, provide placards and describe in shipping documents a shipmeyt of SNM (80-03-02); Infraction -

Failure to monitor packages of radioactive material for surface contamination within three hours after receipt (80-03-03)).

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DOCW.1ENT CONTAINS 100R QUAUTY PAGES u

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REPORT DETAIL 3 1.

Persons Contacted Licensee Employees

  • R. J. Alkema, General Manager
  • E. A. Lees, Manager, Quality Assurance L. J. Kuba, Manager, Materials Operations
  • A. L. Kaplan, Manager, Licensing & Compliance Audits C. M. Vaughan, Manager, Nuclear Materials Management W. B. Smalley, Senior Engineer, Environmental Protection R. C. Keller, Manager, Fuel Chemical Quality Control D. W. Brown, Manager, Powder Production V. P. Moore, Traffic Specialist
  • Attended exit interview.

2.

Exit Interview The inspection scope was summarized on February 12, 1980, with those persons indicated in Paragraph I above.

It was emphasized by the inspector that this special inspection had, to date, only gathered facts, and that findings would be announced in a formal meeting at a l_a,ter date and location to be determined by Region II.

The licensee acknowledged this.

3.

Licensee Action on Previous Inspection Findings Not inspected.

4.

Unresolved Items Unresolved items were not identified d' ring this inspection.

u 5.

Followup on Significant Event That Occurs During Inspection On January 24, 1980, the licensee released for shipment from his Wilmington, North Carolina facility a trailer (number 340217) which was believed to hold only five empty shipping casks (overpacks). All documentation, shipping papers, labels and placards for this shipment were proper for a trailer carrying only empty overpacks.

In fact, however, three of the overpacks contained Model 30B UF cylinders holding approximately 3500 pounds each of 6

1.55% enriched uranium hexafluoride. The licensee's investigation and the Nuclear Regulatory Commission's inspection of this incident and subsequent licensee actions are discussed in this report.

The licensee became aware of the inadvertent shipment of special nuclear material at about 8:30 on the morning of January 28.

The Fuel Support (also called Shop Support) Foreman en duty intended to unload trailer number 340217 that morning, but his Material Control Operator was unable to locate the trailer.

A check with the shipping clerk revealed that trailer 340217 had departed for Allied Chemical Corporation in Metropolis, Illinois on January 24.

The Shop Support Foreman passed this information to the Production Control Specialist, teho, after confirmation from Allied Chemical that the tamper-safe seals on the overpacks were intact, instructed Allied Chemical to dispatch the truck back to Wilmington. Higher levels of licensee management were subsequently informed of the situation. When the General Manager learned of the event, he directed that the trailer, already enroute back to Wilmington, be diverted to the nearest carrier (Tri-State Motor Transit) terminal, which was at Goodlettsville, Tennessee. At about 5:15 p.m. on January 28, the NRC (Region II) was notified of the incident. A licensee Traffic Specialist was dispatched on the evening of January 28 from Wilmington to Goodlettsville with correct shipping papers and labels to document the radioactive cargo. On his arrival at the terminal he affixed the prdper labels, provided proper shipping papers, verified the overpack seal numbers, and ascertained that the truck driver had properly placarded the trailer prior to leaving Allied Chemical.

Trailer 340217 arrived at the Wilmington facility at 8:45 p.m. on January 29.

Under the observation of licensee management and two NRC inspectors (on site to perform a routine, unannounced material control inspection), the tamper-safe seals were broken, the overpacks opened, and the cylinders removed and weighed; weights agreed with those specified by the supplier of the UF

  • 6 On January 29, 1980, the licensee dispatched a letter to the NRC (Region II) outlining the immediate corrective actions taken to prevent a recurrence of this incident. Basically, the licensee committed to handle empty shipments identically to full shipments in that the " contents" of empty shipments would be verified and documented on a weigh sheet prior to issuance of a shipping notice.

A more detailed chronology of events is included in the licensee's investi-gation report (Exhibit A to this report). The NRC inspectors already on site verified the condition of the trailer, overpacks, and cylinders upon their return to the licensee on January 29.

Additionally, on January 30 the inspectors acquired copies of pertinent documents, including shipping notices, bills of lading, weight records, and other such items. The inspec-tors informed the licensee that a special inspection would be conducted by the NRC concerning this incident. The licensee assembled a five member investigation team to determine the cause of the incident and to recommend corrective action.

6.

Inspector Dispatched to Site After the licensee's team completed its investigation, a special inspection was conducted by an NRC inspector on site on February 11 and 12.

The inspector was given a presentation by the licensee's investigation team of its findings.

(The written report of this team's investigation is included

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as Exhibit A to this report.) Questions concerning details of the incident were satisfactorily answered by the licensee.

The route followed by Tri-State shipments, both on the Wilmington site and between Wilmington and Metropolis, Illinois, was determined; states through which the shipment passed are North and South Carolina, Tennessee, Kentucky, and Illinois.

Procedures associated with shipping and receiving radioactive materials and handling of UF cylinders were reviewed.

6 Several aspects of this incident appear to have violated NRC regulations.

10 CFR 70.58(h) requires that controls be established and followed to

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provide current knowledge of the location of all special nuclear material

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in discrete containers.

Contrary to this, during the period January 24-28, 1980, the licensee failed to have current knowledge of the location of the i

approximately 10,500 pounds of enriched UF contained in the three subject 6

cylinders (80-03-01).

10 CFR 71.5(a) requires licensees to follow regula-tions contained in 49 CFR 170-189.

By failing to properly describe the radioactive material in the shipping papers, by failing to properly label the overpacks, and by failing to provide proper placards for the trailer, the licensee violated requirements contained in the following subparts of 49 CFR 172: 202(a), 203(d), 403, and 506 (80-03-02).

10 CFR 20.205(b)(1) requires the licensee to monitor all incoming packages of radioactive materials for external surface contamination.

Contrary to this, the licensee failed to monitor the cylinder overpacks on trailer 340217 after receipt on January 23 and prior to shipment on January 24 (80-03-03).

7.

Management Meeting On February 27, 1980, the following representatives of the licensee's management met with NRC staff members in the Region office:

E. A. Lees, Manager, Quality Assurance W. J. Hendry, Manager, Regulatory, Compliance A. L. Kaplan, Manager, Licensing and Compliance Audits The findings of the NRC inspectors were discussed and acknowledged by the licensee.

1 The status of the licensee's current and future corrective actions to

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prevent recurrence of this or similar kinds of incidents was reviewed.

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T EXHIBIT A GEN ER AL h ELECTRIC NUCLEAR ENERGY PRODUCTS DIVISION WILMINGTON M ANur ACTURING DEPARTMENT CAST LE HA Vfd W J All. P. O ItDX 780. WILM ANGTON. N. C. 78401. (91m 3 33-5000 February 15, 1980 4

e.

Mr. James l'.

O 'lh'i ll y, Direct or U. S. Nuc l ea r Regulatory Commission, RII N

101 Mariella Street, NW - Suite 3100 Atlanta, Georgia 30303

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Dear Mr. O'Reilly; z-

Reference:

NRC License SNM-1097, Docket #70-1113 With reference to activit les authorized by SNM-1097 at the General Electric fuel fabrication facility in Wilmington, North Carolina,

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GE hereby sulwnits a report of the recent incident involving the inadvertent shipment of three full cylinders of uranium hexafluoride to Allied Chemical Corporation in Metropolis, Illinois.

Interim actions were taken immediately pending a complete investiga-tion to determine the causes for the incident and what corrective actions are necessary to prevent recurrence.

The investigation has been completed and the necessary corrective actions have been specified.

These corrective actions will be implemented by Monday, February 18, 1980.

General Electric personnel wi)) be pleased to discuss the matter with you and your staff as you may deem necessary.

Very truly yours, GENERAL JLECTRIC COMPANY

{;k llA b /$j$h Arthur L. Kaplan, Manager Licensing & Compliance Audits M/C J26 ALK:bmw INC-D Attachment i

Page 1 of 20 l

GENERAL @ ELECTRIC EXHIBIT A Mr. J

p. O'Reilly February 15, 1980 INCIDENT INVESTIGATION REPORT SH]pMENT OF THREE FULL UF6 CYLINDERS CONTAINING ENRICHED URANIUM TO ALLIED CHEMICAL CORPORATION 1)

INTRODUCTION On Thursday, January 24, 1980, a trailer with five UF6 cylinder overpacks permanently af fixed to it, was dispatched via Tri-State Motor Transport Company from General Electric's fuel fabrication facility in Wilmington, N.

C.,

to Allied Chemical Corporation in Metropolis, Illinois, to pick up and deliver back to GE-Wilmington Manufacturing Department (WMD) five full UFg cylinders containing natural uranium.

At that time, the overpacks on this trailor were thought to be empty.

However, on Monday morning, January 28, 1980, we discovered that three of the overpacks on the trailer still contained full UF6 cylinders containing uranium enriched to 1.557 in U-235, which had been dispatched from Goodyear Atomic Corporation in Sargent, Ohio, and had arrived at WMD at midnight on Wednesday, January 23, 1980.

As soon as this situation was discovered, the trailer was quickly located at the Allied Chemical Corporation facility.

We verified that the seals on the three overpacks containing the full cylinders were still intact and that the cylinders had not yet been removed from their overpacks by Allied.

Arrangements were made for the prompt return of the trailer to WMD.

t Interim actions were immediately implemented to prevent recurrence of such an incident, pending the outcome of a complete investigation into the causes for the incident and into appropriate corrective actions which would be required.

An ini'estigation team was constituted on January 31, 1980.

.This team completed its investigation on February 8, 1980.

This report contains a complete description of the incident and of the subsequent investigation, the-results of the investigation and the corrective actions taken and planned to prevent recurrence of this type of incident.

Page 2 of 20 c)

Mr. J. p. O'Reilly February 15, 1980 EZHIBIT A-Attachment - page 2 2)

DESCRIPTION OF INCIDENT The following is a synopsis of the event s involved in our inadvertent shipment of the full UFg cylinders to Allied Chemical Corporation.

On the morning of Thursday, January 24, 1980, a trailer was sent'to Allied Chemical Corporation i n Metropolis, Illinois, to pick up five full cylinders of UFa containing natural uranium.

The cylinder overpacks are permanently af fixed to the trailer hed.

These overpacks were assumed to be empty by the shipping personnel who dispatched the trailer on Thui sday.

Ilowever,,i n fact, three of the five overpacks each contained a full cylinder of UFg with uranium enriched to 1.551 in' U-235.

On Monday morning, January 28, 1980, the trailer containing the full cylinders was discovered to be gone, when shop personnel began to look for the trailer in order to remove t he full cylinders from t heir overpacks.

T*.41s discovery was not made unti1 Monday morning, as shipping or receiving activities related to UFg cylinders are accomplished during Monday through Friday on the day shift and, therefore, not normally scheduled.for weekends.

At the same. t ime that the tra iler was discovered to be gone from the plant site with three full cylinders still onboard, the shipment of the supposedly em})ty trailer to Allied Chemical

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Corporat ion was confirmed to have occurred on the previous Tllu r.sda y.

Thus, we realized that the trailer with the three full UFO cylinders was in fact at Allied.

The location of the trail er was' confirmed by calling Allied.

A1so, we confirmed that.the cylinders had not yet been removed from their overpacks and that the Goodyear Atomic Corporation (GAT) seals on the external surfaces of the three overpacks containing cylinders were still intact.

Therefore, arrangements were made for prompt r + urn of the trailer to WMD.

Following notification of the management at WMD, the NRC was promptly notifled.

The truck driver hauling the trailer was provided with appropriate shipping papers and labels for his return trip, and. the integrity and icjentity of the GAT seals on the over-packs werd verified, by a WMD traf fic specialist who met the truck enroute.

Page 3 of 20 w

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o Mr. J. P. O'Reilly February 15, 1980 EXHIBIT A A t tac hment - Page 3 On Tuesday, January 29, 1980, as soon as the trailer returned to WMD, the int egrity and ident ity of the tampersafe seals on the cylinders within the overpacks and the gross weights of these cylinders were ver i f ied by WMD personnel, wit nesserl by two NRC inspectors from the NRC Region II office who happened to be on the WMD site conducting a routine, unannounced safeguards inspection.

A more detailed chronology of events is listed in Table 1.

An organization chart showi ng the relative organizational levels of VMD personnel involved in the incident is included in Table 2.

Figure 1 shows a schematic layout of the WMD fuel manufacturing plant, wit h t he st ructures and road wa y s, specifying t he roadwa y and building areas involved in shipping and receiving loaded und empty Uro cylinder trailers.

Table 3 contains a 1ist of highway routes between cities taken by the truck driver hauling the trailer containing the three full UFg cylinders.

This routing description was obtained from the payroll department of Tri-State at Joplin, fli ssour i, from records submitted by the driver.

An investigation team was constituted'on Thursday, January 31, 1980, to determine the causes for the incident, review the practices and procedures related to the handling of incoming and outgoing shipments of UFg cylinders (including empty trailers) and to recon:nend corrective actions for prevention of recurrence of such an incident.

The investigation was completed,on Friday, February 8, 1980.

This report contains the findings and corrective actions taken and the corrective actions planned as a result of the i nvest iga t. ion.

3)

ACTIONS TAKEN Dion discovery on Monday morning, January 28, 1980, that the i

trailer with three full UFO cylinders had been inadvertently sent from WMD to Allied, a number of actions were taken immediately to recover the trailer and to prevent recurrence of such an incident pending the completion of the resulting i nves t fga 1. io n.

1.

l.ocation of the Cylinders The location and condition of the trailer were verified

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with Allied Chemical Corporation as soon as the Allied plant opened at 8:00 AM CST on Monday morning.

Page 4 of 20 I

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Date Time **

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1 1/23/Nf t T r.a s l + r #13 30!!. depa rt. d trom Goodyeaa Atomic Corpor.ition in Satgent. Ohio. for GE-

. W i t n i fig t. o. it.uiu t ar t ur ing t hepa r t men t (Witte) carrying f ive tull c yl indet s v1.13g.in g.

ov e rp.o k :,.

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2 1/03/80 loWJ T r.s a l e r r3 :o217 departed f rem Goodyear f or CI;-mfd ra rrying thr.e full cylinjetu of

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y, (T6 w a t h uran nen en richest to 1. *.*d in U-235.

(Tisme.yltn.ter.- were not f ill

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1/23/60

  • 1 Wit' 1 ra i l er 8131:31:, a r r i ved a t GI. Mit s w t '. h five tult cylinders of IIP and was pa rked 6,

ou t :. a d e and techtent the ba c k o f the fuel %f anu f act s.r t ng thaild ing 4

1/23/30 2337 Tratler al10217 arrived at GEd\\f ts.

It w.as' parked on the ro:tdway behand and o:stande of Ihe l'tse t it.in o f a c t u r i ng Buitding. waitiog to I.e brought inside t he I,u i ! d i ns: !or the cylinders to lee regnoved f rom their overpacks.

5 1/24/80 0730

.The production Control Specialist notified t he cylinder dock 'faterial Contrul Operator

( t!CO ) f or Siiop Supimr t to remove the full cylinders t roin t ra iler #131015 and t railer 8310217 so that they could leave empty as scheduled. One was to leave e,n Saturday, 1/25/HO and t he ot her on '.tonda y. 1/2M/80, to pick up full cylinders of UF6 with na t.a r a l u ra n t u:::.s t A l l i ed C hero ica l Corporation, tie t rn po l i s, Illinois.

A i

fi 1/21/80 0900 T he' d i t.pa t c he r for Tri-State Etotor Transit Company (in the terminal bu t i d a n:.; tocated outside of the GE-mfd gate) called the Shipping Clerk and asked him if at weuid f >e poasihte for t he driver to pick up a traller on the same day (Thursday) so th.st the driver could get some repair work done on his t r.a c t o r a t Knoxville. Te'nn es we,

enreute to Alli d

f.

The Shit ping Clerk and t he produc t ion Cont rol Spec ial'st bot h d iscussed t he mat t er i

wi t h t he Tr : 4;ta te's d ispatcher on t he telephone and agreed to the new arrangtment.

7 1/21/H0

,.018.10 The productton Control S pec ia l i s t issued two Requemt s for Shippeng Notices for t ra i l er s m 131015.in t a34 0217 to depart f rom GtGwntil in an empt y cond it ion to Allied Chm ica l Corpi e g a t ion, "etropolis, Ittinois (a normal shipping procedus e for all fuel-related

.,h i pmen t s ). These trailers were to pick up full cylinders of UF6 containing natural uranium.

8 1/24/MO sl000 The Shipping Clet k cornpleted the Shipping Notices for t ra ilers al34015.and *310217 to d epa r t empt \\ tor All3cd, indicating five empty overpacks on each t r:i n t e r. The Shipping Clerk called t he Trt-State dispatcher and told him that t he S h i pp i n.-

Notice for wheeb the d i stwa tc her had respicated an earl y depa rt tare was ready,

  • The luet teens of overpac ks for IW ; rylienters a re permanently art 6xed to the t ra il er beds by twel t s.

(The terminology "overpacks" g

und " casks" are synonpaens.)

    • All times indicat ed are East ern St,andard Time.

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EXHIBIT A s

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Date T e r'.

D e

  • r r g. i o u t. ___.. _.

r et 21 1/28/8o 09,n.

Th. Tri m..er',

d r iver wa s nottitea by A l l i c,i to s.s ko his trailer back to t.I -?.un.

'y to.a,.

The aris. r p t a' a r.h d h i s e rn. A with appropriat.. "ita d ioac t i ve and "Corrusive" B-p l.o r.ii d a hs. s o r.

le..ing A l l t eel.

C' 3

22 1/28/M0 1u44 Trailet G lo21i left it1ied Uf. <nte.at Corporalton, 'let ropo t t h, !!Iinois.

-P I

23 1/2H/80 1300 The pre.duc t ion 8'ont rol Sper' l a l i s t informed t lie produ. tion Contaal Unit M.ina ar a bou t t h.

s i t ua t i ort.

T 2-1 1/28/80 1315 The preatuct teen f*on t rol " nit Manager told t he Traffic Spec s a t i st, tint Ma na ge r-l. i een s i ng G fu Compliane. A u t i t t, ( IAU A ),.and t he-Manager-Traffle F. M.s t e r i a l Distritention f T.Ct D ).

~

an ha us t Ihe. i t mi t ie m.

m 25 1/2M/HO 1330 The production Jontrol Unit Manager, t he Manager-IACA and t he Traffic Specialist told t he M.in tv e r-P rocu r..ren t L Matyrial !.og i:,t ti:s a nd t he M.anager-Nuclear Ma t eria l s Managemen8 :al ou t tbo satuation.

26 1/28/80 1100 The Geto.ral *Janager, GE-hMD, mas informed about the inadvertent s h i n onen t of Ihe t'b ree fuit cy l i ndors t o A l t leed Clusn ica l Corpora t ion. Hu directed that the truck he i n t erreept ed by the Tri-Stato's t erm i sta l manager, if necessary, and t h at the driver he sent to t hu Tri-Stat e's terminal in Goodlettsville, Tennessee to am.ast d ispat c h o f pre.per :.h a pping papers f rom GE-WD.

27 1/28/80 1630 The Tr1 ';ta te's trnek with trai1er #310217 ca11ing.i n f rom f.ebanon, Tennessee (25 g miles cast of Nashville), was directed t o t he Goodlet tsvil le terminal, v.h sc h is about 15 miles nurth of Nashville.

28 1/28/80 1715 The Lf;s nager-D.CA repo r t est the incident to William !!. Kenna, Chief of the Sa f egu a rd s Dranth. Nite lh gion I1 orIice.

29 1/2H/80 1955 The Tra t r ic Special ist departed friwr. Wilmington by airplane to Nashville, Tenneuaee, 30 1/28/HO 2300 The Traffic Specialist met the truck with trailer v310217 at the Goodlettsville terminal an' provided t he trnck driver with the proper shipping papers.

lie affsxed the propes l a be l a.ind markings to t he out side surf aces of the cylinder overpacks and verifsed that t he Cornlyear sea la on the overpacks were still intaeL.

lie al so con f i e rced w i t h the t ruck driver t ha t the t ruck had been proper ty placarded by the drtver hefer* it left Al lied Chemical Corporat ion aml he veri t t ed that the

~

proper placards were sti1I on the traiter at t he t;oodl et t ur i t l e t erm i na 1.

31 1/29/HO 0300 Trailer #340237 left t he Good l e t t,v i l l e t erm i na l for tibWMD.

33 1/29/HO 2thld Trailer #310217 arrived at GE-WMD.

33 1/29/MO 2200 The Manager-lM *A and t wo NitC inspectors (in Wilmington to perform a routine, un-annonneed

.a l eg o.i t.l s inspection at the plant site) arr iveu onsit o.

They checke d and versited t ha t the Goodyear seats on th: overpacks *ere still i ns t a c t.

Page 7 of 20

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EXHIBIT A Attachment - J' age 9 LLCi.:lD A

1,c a. ',;.r ut, J f. L,r pa r k i n ;

j inco;ni n J l'F(. Cyl inder tra ilers termr to unlomlii. ;

a r. ! : >r pa t ing ou t 30in !

UF6 ci linder ' rai1 ers.

N.

N

!1 Locaticn inr.i h the rut 1

?cnuf act uring fiu).1rling

- y' N,-

where UP cylinders cre rc.-eved bram or placcd into overpac:*. on t ra j le- -

s C

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are also 1ctJge-1 in ar..! out at this point}

(y%

Gate at ir.n.;r f er.cc perimeter thrcugh ur.ich

.',[ ' ~

't in con i na.- and cutgoing UF e.

G S h i p: T o r. t r, p.: S c ( c. s '. ~ 11

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GENERAL ELECTRIC COMPANY WILMING TON MANUFACTUr,1NG DEP T,

SITE PLOT PLAN Page 11 of 20

0 EXHIBIT A TABLE 3

.' [.

n

. LIST.OF-ROUTES BETWEEN CITIES USED IN CYLINDER SIIIPPING INCIDENT o.

E e

' Route Date Direction From To

i

'ts 1/24/80-US 117 South Castle Ilayne, NC (GE-Wild)

Wilmin:; ton, NC p

US 74 West Wilmington, NC Lumberton, NC S'

I 95 South Lumberton, NC Florence, SC y

I 20 West.

Florence, SC Intersection with I-26 (SC) o-I 2G West Intersection with I-20 (SC)

Asheville, NC I-40 West Asheville, NC Knoxville, TN 1/25/80 I

40 West Knoxville, TN Nashville, TN I

24

. West Nashville, TN 11etropolis, IL (Allied) 1/28/80 I.

24 East 11etropolis, IL (Allied)

Nashville, TN I

40 East Nashville, TN Lebanon, TN*

I 40 West Lebanon, TN Nashville, TN 4

I 65 North Nashville, TN Intersection with US 31W US 31W East Intersection with I-65 Goodlettsville, TN.(Tri-State)

US 31W West Goodlettsville, TN Intersection with I-G5 I

65 South Intersection with US 31W Nashville, TN

-.~1/ 29/ 80 I

40 East Nashville, TN Asheville, NC I

26 West Asheville, NC Intersection with I-20 (SC)

I 20 East Intersection with I-26 (SC)

Florence, SC I

95 North Florence, SC Lumberton, NC

-US 74 East Lumberton, NC Wilmington, NC

'US 117 North '

Wilmington, NC Castle Ilayn'e, NC (dE-Wild)

  • Point where driver was instructed to proceed to Tri-State terminal in Goodlettsville, TN.

A.

L. Kaplan 2/15/80 Page 12 of 20

Mr. J. P. O'Reilly

' February 15, 1980 EXHIBIT A Attachment - Page 11 3)-

1. (continued)

We were i n f o rmed t.ha t Allied had not yet removed th'e full cylinders from their overpacks and, in fact, that the Goodyear Atomic Corporation (GAT) seals on the outside of the overpacks were still intact.

2. Arranging for Prompt Return of Cylinders A t. the time that the location of the cylinders was verified, the prompt return of the trailer to WMD was arranged.

Allied was requested to contact the driver of the vehicle that hauled t. h e trailer there and to instruct him to 1 cave as soon as possible for WMD to return the trailer.

Before t he driver lef t Allied, he placarded his vehicle correctly with the DOT required RADIOACTIVE and CORROSIVE placards.

3.

Informing WMD Management Bet ween 9: 00 AM and 2:00 P'.! on Monday, January 28, 1980, various levels of WMD management were informed about the i n c i d en t., as each one could be located and contacted.

4. Correct Shipping Papers for Truck Driver At 4 :30 PM on !!onday, January 28, 1980, the truck driver hauling tho returning tra iler was contacted in Lebanon,

Tennessee, twenty-five miles east of Nashville, Tennessee.

lie was directed to proceed directly to the nearest Tri-State's terminal located at Goodlettsville, Tennessee, fifteen miles north of Nashvifle.

A t. 11:00 PM on the same day,'the traffic spe$ialist from GE-WMD arrived at Goodlettsville and provided the truck driver with the proper shipping papers for his load.

5. Correct Lahels & Markings, Integrity of Seals on Overpacks At t he same t ime that he delivered the correct shipping papers to the truck dirver as noted above, the traffic specialist a f fixed the proper labels (RADIOACTIVE, CORROSIVE) and markings (URANIUM IIEXAFLUORIDE - FISSILE) to the external surfaces of the three overpacks containing the full UFg cylinders.

lie also assured that the Goodyear Atomic (GAT)

L seals on the.three overpacks were intact.

The numbers on these seals were verified by calling Goodyear'the next morning.

Page 13 of 20

- - ~ ~ ~ ~ ~ ~ ~ " '

m_.,

. ---.a

Jir. J. P. O'Reilly February 15, 1980 EXHIBIT A

- Page 12

' Attachment 3) 6.

Implementation of Interim Procedure An interim procedure was implemented on Tuesday morning, January 20, 1980, to assure that a trailer being dispatched as empty from the plant is really empty prior to its dispatch.

The procedure (issued as a letter by managrment to the approprtate personnel involved in preparation of the empty

t. railer for shipment) calls for the same overchecks on an empty trailer as those which would be used for a trailer being dispatched with full cylinders or with empty cylinders

( heel s) to assure that_the outgoing trailer contents are correct.

This interim procedure-will be followed until final corrective actions are implemented.

In addition, we implemented the weighing of each empty cyl inder t ra iler leaving the plant site using our recentl y installed truck scales, as a final overcheck until permanent corrective actions can be implemented.

7.

Investigation A managemont team was const i t uted to investigate the causes for the incident and to determine what final correctivo actions should be taken to prevent a recurrence.

The ten:n completed its investigatJon on Friday, February 8, 1980.

l The investigation consisted of the following element s:

e Interviews with personnel involved in the incident.

e Reviow of events relat ed to the incident.

I e

Review of shippini;/ receiving practices related to UF6 cylinders.

s An outlino o f these shipping / receiving practices is shown i

in Table 1.

A list of the related procedures is given in' l

Tabic 5.

4)- CAUSES FOR. INCIDENT M_[ result of the investigation, the causes for the incident r

were. established to be as follows:

1. System l

The system for shipment of trailers with empty overpacks dif fered ' from that used for trailers with loaded overpacks (i.e.,

full cylinders or heels).

(continued on Page'16)

-Page 14 of 20

.o Mr. J.

I'.

O 'Iteill y February.15, 1980 Attachment - l' age l a NBU A TABl.!? 5 PRACTICES FOR_ SHIPPING / RECEIVING UF6 C YL IRDER S

' ACTION ACTIVITIES WMD PROCEDURES FULL TRUCK 9 BILL OF LADING ISSUED BY NONE - NO WMD SHIPPING /

LEAVES VENDOR RECEIVING ACTIVITIES VENDOR SITE 9 SNM (ONLY ONES RELATED TO

- CYLINDERS TAMPERSAFED SAFEGUARDS)

- OVERPAC KS SEALED 9 SOURCE MATERIAL

- NO TAMPERSAFING R EQU IR E-ItENT

- NO SEAL ING R EQ'J IR EMENT (?)

9 TRUCK PLACARDED I U L t.

TRUC K 9 CALLS FFOM DRIVER TO 9 WRITTEN AGREEtiENT s

F. N R O U l E D I SPATCilER AT TRI-STATES' TO UMD 11AIN TERMINAL 9 LETTER INSTRUCTIONS 9 CALLS FROM TRI-STATES TO TO GUARD WMD FULL TP.UC K 9 TRUC K LOGGED IN THROUGH 9 LETTER INSTRUCTIONS ARRIVES AT GATE ONTO SPECIAL TRUCK TO GUARD -

WMD LOG TRUCK AWAITS-9 MONITORED FOR SURFACE 9 NSI'S O-6.0 & 0-17.0 UNLOADING CONTAMINATION BY RADIATION PROTECTION TRUCK IS 9 RECEIVED BY SHOP SUPPORT 4 P/P 90-1 UNLOADED 0 CYLINDERS REMOVED FROM 9 NMMP'S 1 01, 106, 109, OVERPACKS 202, 204, 301, 501 0 CYLINDER SEALS CHECKED 9 PROD 80.05 (IF ANY)

G MICS OP NO S-1 9 CYLINDERS WEIGHED AND 9 QCil 2.7.1.1 ENTERED INTO MICS 9 QCOR 2.7.1.15 9 C YLINDERS SUBJECTED TO MICS AUDITS 9 S/R DIFFERENCES COMPUTED AND EVALUATED TRUCK IS WITil CYLINDERS AND HEELS:

9 P/P 90-t & P/P 90-5 RETURNED TO 9 REQUEST FOR SHIPPING 9 PROD 80.05 VENDOR' NOTICE ISSUED 9 QCil 2.7.1.2 9 SillPPING NOT ICE ISSUED 9 'QCOR 2.7.1.15 9 StilPPING PAPERS ARE 9 NMMP'S 202 & 204 PREPARED 9 NSI'S 0-6.0 & 0-17.0

9. TRUCK SURVEYED FOR CONTAMINATION 9 OVERPACKS LABELLED G TRUCK PLACARDED Page 15 of 20

hl r. 'J. 15 O'Ileilly Fiibrua ry 15',

1980 EXHIBIT A A t. L ac hms'n t.. -- l'a sp 1,1 Tabl e 5 (cein t.i nitect )

ACTION ACTIVITIES WMD PROCEDURES

. TRUCK ~IS EMPTY TRUCK:

O P/P 90-5 RETURNED TO 9 REQUEST FOR SHIPPING NOTICE 9 N S I ' S 'O - 6. 0 & 0- 17. 0 VENDOR ISSUED (CONTINUED) 9 SHIPPING NOTICE ISSUED 9 SHIPPING PAPERS ARE ISSUED 9' TRUCK. SURVEYED FOR CCt! TAM itJAT ION 9 OVERPACKS LABELLED " Et/ T S TRUCK PLACARDED TO REFLt.T EMPTY STATUS a

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J.

p. O'Reilly February 15,-1980 EXHIBIT A Attachment - Page 16 4) 1.

(continued from Page 12)

For a trailer being shipped out as loaded, there are positive checks in the system at each stage of preparation for shipment to assure that the right cylinders are in the overpacks on a specific trailer prior to the shipment.'

For a trailer being shipped out as empty, there was no such_ positive check that the overpacks on this trailer were in fact empty prior to the shipment.

2. Commusications Communications between the different organizations responsible for various phases of preparing for the shipment of empty UF(; cylinder trailers, were in many cases verbal (i.e..

which trailer would be shipped at what time, when the trailer would be ready for shipment, etc.).

3.

Instruct ions There wre no written instructions provided to shipping or production control personnel concerning the shipment of empty UFG cyl inder trailers.

5)

COllitECTI VI: ACT1ONS As a result of the incident investigation, the following corrective actions werel: determined as required to prevent recurrence of this type of incident:

1.

Items Related to Shipping Empty Trailers

~

The preparitory steps related to the shipping of empty overpacks_(i.e., empty UFG cylinder trailers) will be changed to coincide with those for shipping full cylinders or heels.

A flow chart depicting these activities is shown in Figure 2 A " travel er" which, in fact, will be a modified cylinder weigh sheet, will accompany the paperwork for these shipments.

No steps in-the shipping activity will be without proper execution of this traveler for.the previous,

~

stcp, thus providing verification at each step of the activity that the previous steps have been accomplished correctly.

Page 18 of 20

y Mr. J. P. O'Reilly EXHIBIT A February 15, 1980 A t.taclanen t - Page 15 TABLI: G GE-WMD INTERNAL INSTRUCTIONS FOR RECEIPT & SHIPMEt1TS OF UF C YL INDER S 6

_ PRACTICES S PROCEDURES P/ P -.9 0 - 1 RECEIVING & SHIPPING OF RADIOACTIVE MATERIALS 90-3 FUEL SHIPPING CONTAINER CONTROL 90-5 SHIPPING NOTICES QUALITY CONTROL INSPECTOR INSTRUCTIONS QCII 2.7.1.1 INSPECTION OF UF 6 CYLINDERS 2.7.1.2 INSPECTION OF THE PROTECTIVE PACKAGING OF UF 6 CYLINDERS QUALITY CONTROL OPERATOR REQUIREMENTS QCOR 2.7.l.15 RECEIVING S SHIPPING OF UF 6 CYLINDERS PROCESS REQUIREMENTS E OPERATOR DOCUMENTS PROD 80.05 RECEIVING / SHIPPING UF CYLINDERS 6

TRAFFIC 6 MATERIALS DISTRIBUTION INTERNAL INSTRUCTIONS FS-2-1.

PREPARATION OF REQUEST FOR SHIPPING NOTICE 3-1 PR EPARATIO.N 6 D I STR IBUT ION OF SHIPPING NOT ICE 4-1

' PR EPAR AT ION OF BILL OF LADING 5 PRODUCT MATERIAL Sji!PMENTS 6-1 HOLD ON SHIPMENT 7-2 RADIOACTIVE MATER I ALS SHIPMENTS NUCLEAR ttATER I ALS MAtlAGEMENT' PROCEDURES NMMP 101 SOURCE DATA CONTROL 106

_ EVALUATION OF CUMMULATIVE SHIPPER / RECEIVER DIFFERENCES 109 NUCLEAR MATERIAL RECEIPTS 202 NUCLEAR MATERIAL SHIPMENTS 204 DOE /NRC 741 FORl1 301 UF6 SURVEILLANCE BY GE-501 UF SURVEILLANCE, SAMPLING S ANALYSIS 6

NUCLEAR-5AFE'IY INSTRUCTIONS NSI O-6.0 SURFACE CONTAMINATION MEASUREMENT & CONTROL 17.'O SHIPMENT & RECEIPT OF RADIOACTIVE MATERIALS Page 17 of 20 o

EXHIBIT A FIGURE 2 N

SHIP'.!ENT OF UF CYLINDERS & UFn CYLINDER OVERPACKS*

k g

SHOP SUPPORT FADIATION FUEL CHE:4ICAL.

PRODUCTION 3

UNIT

?PCTECTICS CUALITY CO::TEOL I;:'M COSTROL T & L-)

  • c p

MARK AND LABEL n

FOR TRANSPORT O

Y INITIATE CYLINDER CHECK CYLINDER, 9 INSPECT PER

{

WEIGH SHEET Y

CVERPACK AND QCII

)

TRUCK FOR 2.7.1.2 i

CONTAMINATION

/

s SIGN-OFF APPLY TAMPER-CYLINDER WEzGH SAFE SEALS SHEET a

VERIFY DROPER L78ELUG r

4 SIGi-OFF CYLR; DER VERIFY PEOPER h'EIGI SHEET

-)

b'EIGIT 4

SIC;-OFF CYLU[EN E;ITIATE VERIFY OCIIPIf! ION h'EIGC' SI E 4

RD;). FOR

q. OF CYLU; DER KEIGi SHIPPING SHEET YJCICE PREPARE SHIPPING MIC & BE T
  • Full or partially full cylinders in overpacks, cylinders with heels or empty c.ylinders wit') or 'without overpacks, or empty overpacks
Enr, Page 19 of 20 e

.Mr. J. P. O'Reilly

< bruary 15, 1980 EXHIBIT A

-At.taciunent - Page 18 e

2.

Procedures In order to impl emen t.

these activities, the following procedures (see Table G) will be revised:

o P/P 90-1 Receiving &. Shipping of Radioactive Materials e

P/l' 90-5 Shipping Notices e

PROD 80.05 Receiving / Shipping UFG Cylinders e

QCII 2.7.1.2

. Inspection of the Protective Packaging of UFG Cylinders The production control personnel will be provided with their instructions in the revised versions of P/P 90-1 and P/P 00-5.

In addition, a new fuel shipping procedure will be pr'epared to provide appropriate instructions to shipping personnel.,

These proendures wil] be revised or prepared as required and will be implemen ted by Monda y, February 18, 1980.

Page 20 of 20 l

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