ML20024J252
| ML20024J252 | |
| Person / Time | |
|---|---|
| Site: | Fort Calhoun  |
| Issue date: | 10/06/1994 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| Shared Package | |
| ML20024J250 | List: |
| References | |
| 50-285-94-20, EA-94-193, NUDOCS 9410130077 | |
| Download: ML20024J252 (20) | |
Text
i i
ENCLOSURE 1 NOTICE OF VIOLATION 1
Omaha Public Power District Docket: 50-285 Fort Calhoun Station License: DPR-40 EA 94-193 During an NRC inspection conducted on August 30-31, 1994, a violation of NRC requirements was identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2, Appendix C, the violation is listed below:
10 CFR 50.54 (q) requires, in part, that a licensee authorized to possess and operate a nuclear power reactor shall follow and maintain in effect emergency plans which meet the standards in 50.47(b) and the requirements in Appendix E of this part.
The Fort Calhoun Station Radiological Emergency Response Plan, Section D, paragraph 2.0 states that specific criteria are provided in the Emergency Plan Implementing Procedures for the recognition, characterization, and declaration of each of the emergency classifications.
Section D, paragraph 2.2 states, in part, that a Notification of Unusual Event is generally characterized by abnormal plant conditions which, by themselves, do not constitute significant emergency conditions. Some of these events could indicate a potential degradation in the level of plant safety and/or escalate to a more severe condition if appropriate action is not taken. The primary purpose for this classification is to ensure that the plant operating staff recognizes the initiating condition, takes appropriate action, such as assessment and verification, and comes to an appropriate state of readiness to respond in the event that the condition worsens.
Emergency Plan Implementing Procedure EPIP-0SC-1, Revision 23,
" Emergency Classification," Section 5.4, requires that the Shift Supervisor / Site Director turn to the appropriate Emergency Action Level (EAL) page in Attachment 6.1, Emergency Action Level Verification Criteria and Applicable Modes. Section 5.4.1 requires that if verification is made Declare the Emergency Classification Indicated..1, EAL 11.6 requires, in part, that a Notification of Unusual Event be declared for:
1.
Any plant condition exists that warrants increased awareness on the part of a plant operating staff or state authorities.
OR 2.
An event is in progress or has occurred which indicates a potential degradation of the level of safety of the plant.
941013o077 941006 ADOCK 05000285 G
i Contrary to the above requirement, on May 26, 1994, a Notification of Unusual Event was not declared at or about 3:25 a.m. following an event involving a toxic gas release in the turbine building such that a potential degradation of the level of safety of the plant existed, and which warranted increased awareness on the part of plant operating staff.
Specifically, at about 12:40 a.m.,
a leak was identified on a concentrated hydrazine storage container located in the turbine building (within the protected area). At about 3:25 a.m., an attempt was made by i
the shift chemist to neutralize the hydrazine with concentrated hydrogen peroxide. A violent exothermic reaction occurred resulting in the release into the turbine building of a large cloud of reaction products.
As a result of the reaction, the shift chemist was dazed, and received chemical burns to his arms. As a result of these events, toxic gases were present in the turbine building in concentrations th t would not be measured for several hours. These conditions warranted it. creased awareness on the part of the plant operating staff and had the potential for degrading the level of safety of the plant by affecting operations personnel, or by restricting access tc affected plant areas. [01014]
This is a Severity Level IV violation. (Supplement Vill).
Pursuant to the provisions of 10 CFR 2.201, Omaha Public Power District is hereby required to submit a written statement or explanation to the U.S.
Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, D.C.
20555 with a copy to the Regional Administrator, Region IV, 611 Ryan Plaza Drive, Suite 400, Arlington, Texas 76011, and to the NRC Resident Inspector at the facility that is the subject of this Notice, within 30 days of the date of the letter transmitting this Notice of Violation (Notice). This reply should be clearly marked as a " Reply to a Notice cf Violation" and should include for each violation:
(1) the reason for the violation, or, if contested, the basis for disputing the violation, (2) the corrective steps that have been taken and the results achieved, (3) the corrective steps that will be taken to avoid further violation, and (4) the date when full compliance will be achieved.
If i
an adequate reply is not received within the time specified in this Notice, an order or a Demand for Information may be issued to show cause why the license should not be modified, suspended, or revoked, or why such other action as may be proper should not be taken. Where good cause is shown, consideration will i
be given to extending the response time.
t i
Dated at Arlington, Texas this 6th day of October 1994 l
t i
e ENCLOSURE 2 LIST OF ENFORCEMENT CONFERENCE ATTENDEES AT NRC REGION IV 0FFICE, ARLINGTON, TEXAS i
Omaha Public Power District l
W. C. Jones, Senior Vice President W. G. Gates, Vice President R. L. Andrews, Division Manager, Nuclear Services J. W. Chase, Plant Manager, Fort Calhoun Station D. R. Trausch, Manager, Nuclear Licensing & Industry Affairs
- 0. J. Clayton, Supervisor, Emergency Planning F. K. Smith, Supervisor, Chemistry R. T. Ridenoure, Shift Supervisor R. C. DeMeulmeester, Shift Supervisor i
Nuclear Regulatory Cc, ission J. M. Montgomery, Deputy Regional Administrator R. A. Scarano, Deputy Director, Division of Radiation Safety and Safeguards (DRSS)
B. Murray, Acting Chief, Reactor Inspection Branch W. D. Johnson, Chief, Project Branch A, Division of Reactor Projects G. F. Sanborn, Enforcement Officer D. B. Spitzberg, Senior Emergency Preparedness Analyst, DRSS R. P. Mullikin, Senior Resident Inspector, Fort Calhoun Station S. L. McCrory, Acting Branch Chief, Operations Branch, 3
Division of Reactor Safety J. L. Beall, Senior Enforcement Officer, Office of Enforcement S. Bloom, Project Manager, Office of Nuclear Reactor Regulation 1
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SEPTEMBER 27.1994
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tC ENFORCEMENT CONFERENCE AGENDA 1.
OPENING REMARKS Bill Jones 11.
EVENT DISCUSSION Ross Ridenoure Bob DeMuelmeester a Event Review Fred Smith a Chemistry Response /
Instrumentation i
Ill. ROOT CAUSE Dick Andrews a Event Cause(s)
I u Safety Significance IV.
MANAGEMENT ISSUES / LESSONS LEARNED Jim Chase i
m Corrective Actions e Other Initiatives V.
EVENT TIMELINE Gary Gates VI. REVISION TO EPIP-OSC-1 Jay Clayton Vll.
SUMMARY
/ CLOSING REMARKS Bill Jones
OPENING REMARKS a
introduce OPPD Participants a
OPPD Presentation Format and Presenters l
2
EVENT DISCUSSION a
Event Review Event Chronology of May 26,1994 e
0040 Hydrazine leak discovered under the chemical totes in the Turbine Building (T/B) truck bay, personnel initially exposed to Hydrazine.
0100 Two Non-Licensed Operators and the Shift Technical Advisor (STA) isolate leak.
0100 Shift Chemist reports 2.9 pounds of hydrazine leaked out (State Limit is 1 pound).
0115 Shift Supervisor (SS) contacts Acting Supervisor - Hazardous Materials (HazMat) and recommends that cleanup wait until dayshift, and that in interim area should be isolated. Area directly around the hydrazine totes is roped off and entry into the truck bay restricted.
0140 Management notifications made from 0130 to 0140. Plant Manager requests that leak be cleaned up on night shift.
3
i EVENT DISCUSSION (Continued) a Event Review'(Cont.)
0155 Shift Chemist notified that hydrazine neutralization will occur on night shift.
Chemist begins making preparations to
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neutralize with hydrogen peroxide.
1 0245 Acting NRC Site Resident notified of hydrazine leak and the requirement to notify State of Nebraska based on the amount leaked.
0325 Shift Chemist attempts to neutralize leak with Hydrogen Peroxide. Strong chemical reaction occurs that produces a large vapor cloud and splashes some hydrogen peroxide on the Chemist's forearms.
0330 Neutralization effort suspended.
t 0355 Various management notifications made-I between 0335 and 0355. Supervisor -
)
Chemistry and Acting Supervisor - HazMat requested to come to site.
0409 NRC Operations Center in Bethesda notified of intent to notify State of Nebraska of the hydrazine leak.
4
EVENT DISCUSSION (Continued) m Event Review (Cont.)
= 0415 Shift Chemist notified to begin taking air samples to determine levels of hydrazine in the atmosphere.
0430 Turbine Building truck bay is posted as a hydrazine leak area, based on the recommendation of the Supervisor -
Chemistry.
0500 The Supervisor - Chemistry, Acting Supervisor - HazMat, and a HazMat trained Chemist arrive in Control Room between 0445 and 0500.
0505 The two operators and STA involved with the initial response to leak inform the SS that they had experienced some physical effects at the beginning of the shift due to exposure to hydrazine fumes.
Dizziness lasting = 15 minutes, some nausea and headaches lasting 2-3 hours were apparent earlier in the shift but are now diminished.
0648 Initial samples results in the T/B truck bay indicate hydrazine level around 1.0 ppm.
Chemistry indicates they are taking confirmatory backup samples.
5
EVENT DISCUSSION (Continued) m Event Review (Cont.)
0658 SS directs the placement of a " hurricane fan" in the T/B truck bay to assist with the dissipation of chemical fumes. Turbine Building ventilation had been adjusted earlier in the shift to enhance ventilation in the vicinity of the truck bay.
0725 Off-going Nightshift SS completes turnover to Dayshift SS.
0758 Acting Supervisor - Hazardous Materials reports to both SS' that hydrazine levels in the T/B are as follows:
3.0 ppm on main turbine deck 2.3 ppm in truck bay area 35 ppm beneath the amerzine totes.
0807 Plant Manager notified of sample results by the nightshift SS.
0900 incident responders split up into two teams, one team to initiate leak cleanup and the other team to continue atmospheric sampling.
1056 Leak neutralized and cleaned up.
6 1
EVENT DISCUSSION (Continued) a Chemistry Response / instrumentation e
Chemistry Response Notification Event Response e
Instrumentation i
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Portable Infrared Spectrophotometer (MIRAN 1B) i Liquid Absorbance (Bubbler) 7
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ROOT CAUSE a
Event Cause(s) e Procedure Not Followed (EAL 11.8)
Procedure Weakness (EAL 11.8)
Lack of Designated incident Commander at the Scene Lack of Hazardous Materials incident Response Plan inadequate Modification Acceptance e
No Specific Procedure on Totes Changeout No Specific Training on Totes Changeout 9
F
ROOT CAUSE (Continued) a Safety Significance License Staffing Levels Satisfied e
Operating Crew Fit for Duty e
Access to Safety Related Areas Unaffected Access to Turbine Building Possible throughout e
Event 10
MANAGEMENT ISSUES / LESSONS LEARNED Corrective Actions Address the following:
a Ensuring the Flow of Information is Available and Reliable Providing a Mechanism in which to Effectively e
Deal with a Non-nuclear Incident t
Put Barriers in Place to Prevent Future Incidents Revise Emergency Action Levels to Focus upon e
Impact to Plant Operations l
11
MANAGEMENT ISSUES / LESSONS LEARNED (Continued)
Corrective Actions (Completed) a Chemical Tote and System Integrity Verified Periodic Sampling Around Chemical Totes Developed and Approved a Hazardous Materials incident Response Plan Developed and Approved a Chemical Delivery and Installation Procedure Reviewed Open Modifications /ECNs that have not been Completed (SAC Process) 12
MANAGEMENT ISSUES / LESSONS LEARNED (Continued) a Corrective Actions (in Process)
Identify Chemical Hazard Areas and Pre-Plan Strategies (09/30/94)
Complete Training and Implement Hazardous Materials incident Response Plan (10/31/94) l Evaluate Hazardous Materials incident Response i
Plan Effectiveness (12/01/94)
Evaluate Chemical Addition System for Improvements (10/31/94)
Standing Order G-87 Briefings
)
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Other Initiatives j
Increased Emphasis on Conservative Decision Making 13
1 HYDRAZINE LEAK EVENT TIMELINE 4
First Sample flydrazine Crew Fitness Second Sample >1.0 ppm Obtained.
Leak Leak r Duty
- Questionable Sample in Elec. Pen.
Discovered Attempt Assessed Results Room Cleaned up Results (-1.0 ppm) l 0040 0325 0505 0648 0758 1000 1056 l f l f l f l f I f l f l f t
Potential for Potential for Potential for NOUE ALERT SITE AREA Declaration Declaration Declaration Consistent Approach Questionable Results w/ Sufficient Doubt Familiarity'w/ Hydrazine 14
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o REVISION TO EPIP-OSC-1 1
Unresolved item (URl)
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i URI Response Station / Regulatory Reviews P
Toxic Gas vs. " Generic" EALs at FCS History of Using PELs 1
URI Response Justification EAL Lessons Learned 15 m*
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SUMMARY
/ CLOSING REMARKS Minimal Safety Significance EAL Not Consistent with the Intent of e
NUREG 0654 Self Critical Event Investigations e
e No Willfulness Emergency Planning / Operations SALP e
Perforrnance Acceptable Conservative Emergency Plan implementation e
History Support for Conservative Decision Making e
Hazardous Materials incident Response Plan e
Effectiveness Assessment 16
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