ML20042E896
| ML20042E896 | |
| Person / Time | |
|---|---|
| Issue date: | 03/31/1990 |
| From: | NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD) |
| To: | |
| References | |
| NUREG-0090, NUREG-0090-V12-N04, NUREG-90, NUREG-90-V12-N4, NUDOCS 9005040046 | |
| Download: ML20042E896 (21) | |
Text
I NUREG-0090 Vol.12, No. 4 Report to Congress on Abnormal Occurrences October - December 1989 y
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NUREG-0090 Vol.12, No. 4 Report to Congress on Abnormal Occurrences October - December 1989 Date Published: March 1990 Office for Analysis and Evaluation of Operational Data U.S. Nuclear Regulatory Commission Washington, DC 20555
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Previous Reports in Series NUREG 75/090, January-June 1975, NUREG-0090, Vol.6, No.l. January-March 1983, published October 1975 published September 1983 NUREG-0090-1, July-September 1975, NUREG-0090. Vol.6, No.2, April-June 1983, published March 1976 published November 1983 NUREG-0090-2, October-December 1975, NUREG-0090 Vol.6, No.3, July-September 1983, published March 1976 published April 1984 NUREG-0090-3, January-March 1976 NUREG-0090 Vol.6 No.4, October-December 1983, published July 1976 published May 1984 NUREG-0090-4 April-June 1970 NUREG-0090, Vol.7, No.1, January-March 1984, published March 1977 published July 1984 NUREG 0090-5, July September 1976, NUREG-0090, Vol.7, No.2, April-June 1984, published March 1977 published October 1984 NVREG-0090-6, October-December 1976 NUREG-0090, Vol.7, No.3, July-September 1984, published June 1977 published April 1985 NUREG 0090-7, January March 1977 NUREG-0090, Vol.7, No.4, October-December 1984, published June 1977 published May 1985 NUREG 0090-8. April-June 1977, NUREG-0090, Vol.8, No.l. January-March 1985, published September 1977 published August 1985 NUREG-0090-9 July-September 1977, NUREG-0090, Vol.8, No.2, April-June 1985, d
publisned November 1977 published November 1985 l
NUREG-0090-10, October-December 1977 NUREG-0090, Vol.8, No.3, July-September 1985, i
rublished March 1978 published February 1986 NUREG-0090, Vol.1, No.1, January-March 1978 NUREG-0090, Vol.8, No.4, October-December 1985, published June 1978 published May 1986 NUREG-0090, Vol.1, No.2 April-June 1978, NUREG-0090, Vol.9, No.1, January-March 1986, published September 1978 published September 1986 NUREG-0090 Vol.1, No.3, July-September 1978, NUREG-0090,'Vol.9, No.2, April-June 1986, l
published December 1978 published January 1987 NUREG-0090, Vol.1, No.4, October-December 1978 NUREG-0090 Vol.9, No.3, July-September 1986, published March 1979 published April 1987 NUREG 0090, Vol.2, No.1, January-March 1979, NUREG-0090, Vol.9, No.4, October-Dece6er 1986, published July 1979 published July 1987 NUREG-0090, Vol.2, No.2, April-June 1979, NUREG-0090. Vol.10 No.1, January-Parch 1987, l
published November 1979 published October 1987 NUREG-0090, Vol.2, No.3, July-September 1979, NUREG-0090 Vol.10. Nn.2, April June 1987, published February 1980 published N yember 1987 NUREG-0090, Vol.2, No.4, October-December 1979. NUREG-0090, Vol.10..No.3, July-September 1987, published April 1980 publisted March 1988 i
NUREG-0090, Vol.3, No.1, January-March 1980, NUREG-0090, Vol.10. No.4 October-December 1987, published September 1980 published March 1988 NUREG-0090, Vol.3, No.2, April-June 1980, NUREG-0190, Vol.11, No.1, January-March 1988, published November 1980 pub 1hhed July 1988 NUREG 0090 Vol.3, No.3, July-September 1980, NUREG-0050 Vol.11, No.2, April-June 1988, published February 1981 publishei December 1988 NUREG-0090, Vol.3, No.4, October-December 1980, NUREG-0090, Vol.11, No.3, July-September 1988, published May 1981 published January 1989 NUREG-0090, Vol.4, No.1, January-March 1981, NUREG-0900 Vol.11, No.4, October-December 1988, published July 1981 published April 1989 NUREG-0090, Vol.4, No.2, April-June 1981, NUREG-0900, Vol.12, No.1, January-March 1989, published October 1981 published August 1989' NUREG-0090, Vol.4, No.3, July-September 1981, NUREG-0900, Vol.12. No.2, April-June 1989, published January 1982 published October 1989 NUREG-0090, Vol.4, No.4 October-December 1981, NUREG-0900 Vol.12. No.3, July-September 1989, published May 1982 published January 1990 NUREG-0090, Vol.5, No.1, January-March 1982, published August 1982 NUREG-0090, Vol.5, No.2, April-June 1982, published December 1982 NUREG-0090, Vol.5, No.3, July-September 1982, published January 1983 NUREG-0090, Vol.5, No.4, October-December 1982, published May 1983 i
ABSTRACT Section 208 of the Energy Reorganization Act of 19N identifies an abnormal occurrence as an unscheduled incident or event that the Nuclear Regulatory Commission determines to.be significant from the standpoint of public health-or safety and requires a quarterly report of such events to be made to Congress.
This report covers the period from October 1 through December 31, 1989.
For this reporting period, there were three abnormal occurrences, none involv-ing a licensed nuclear power plant.
Two of the abnormal occurrences involved-nuclear material licensees and are described in detail under other NRC-issued licenses.
The first involved a medical diagnostic misadministration and the second involved a medical therapy misadministration.
The third abnormal occur-rence was reported by an Agreement State (Louisiana) and involved an overexposure to an industrial radiographer.
The report also contains information that updates a previously reported ab' normal occurrence.
3 iii
CONTENTS
.P,ag ABSTRACT..............................................................
iii PREFACE...............................................................
vii INTR 000CTION.....................................................
vii THE REGULATORY SYSTEM.~...........................................
vii REPORTABLE OCCURRENCES...........................................
vii AGREEMENT STATES.................................................
viii FOREIGN INFORMATION..............................................
. ix' REPORT TO CONGRESS ON ABNORMAL OCCURRENCES, OCTOBER-DECEMBER 1989.....
1 NUCLEAR POWER PLANTS.............................................
1-FUEL CYCLE FACILITIES (Other than Nuclear Power Plants)..........
1 OTHER NRC LICENSEES (Industrial Radiographers, Medical Institutions, Industrial Users, etc.)............................
1 89-13 Medical Diagnostic Misadministration...................
1 89-14 Medical Theraphy Misadministration.....................
2 AGREEMENT STATE LICENSEES........................................
3 AS89-2 Industrial Radiographer Overexposure...................
4 APPENDIX A - ABNORMAL OCCURRENCE CRITERIA.............................
7 APPENDIX B - UPDATE OF PREVIOUSLY REPORTED ABNORMAL OCCURRENCES.......
9-
~
NUCLEAR POWER PLANTS.............................................
9 79-3 Nuclear Accident at Three Mile Island..................
9' APPENDIX C - OTHER EVENTS OF INTEREST.................................
11 1.
Significant Degradation of Reactor Fuel Rod Cladding at Haddam Neck..................................................
11 v
PREFACE INTRODUCTION The Nuclear Regulatory Commission reports to the Congress each quarter under provisions of Section 208 of the Energy Reorganization Act of 1974 on any abnor-mal occurrences involving facilities and activities regulated by the NRC.
An
~
abnormal occurrence is defined in Section 208 as an unscheduled incident or event that the Commission determines is significant from.the standpoint of public health or safety.
Events are currently identified as abnormal occurrences for this report by the NRC using the criteria listed in Appendix A.
These criteria were promulgated in an NRC policy statement that was published in the Federal Register on February 24, 1977 (Vol. 42, No. 37, pages 10950-10952).
In order to provide wide dissemina-tion of information to the public, a Federal Recister notice is issued on each abnormal occurrence.
Copies of the notice are cistributed to-the NRC Public Document Room and all Local Public Document Rooms.
At a minimum, each notice must contain the date and place of the occurrence and describe its nature and probable consequences.
The NRC has determined that only those events described in this report, meet the criteria for abnormal occurrence reporting.~ This report covers the period from October 1 through December 31, 1989.
Information reported on each event includes date and place, nature and probable consequences, cause or causes, and actions taken to prevent recurrence.
THE REGULATORY SYSTEM The system of licensing and regulation by which NRC carries out its responsibil-ities is implemented through rules and regulations in Title 10 of the Code of Federal Regulations. This includes public participation as an element.
To ac-complish its objectives, NRC regularly conducts licensing proceedings, inspec-tion and enforcement activities, evaluation of operating experience, and con-firmatory research, while maintaining programs for establishing standards and issuing technical reviews and studies.
In licensing and regulating nuclear power plants, the NRC follows the philosophy that the health and safety of the public are best ensured through the establish-ment of multiple levels of protection. These multiple levels can be achieved and maintained through regulations specifying requirements that will ensure the safe use of nuclear materials.
The regulations include design and quality assurance criteria appropriate for the various activities licensed by NRC.
An inspection and enforcement program helps ensure compliance with the regulations.
REPORTABLE OCCURRENCES Actual operating experience is an essential input to the regulatory process for assuring that licensed activities are conducted safely.
Licensees are re-quired to report certain incidents or events to the NRC.
This reporting helps to identify deficiencies early and to ensure that corrective actions are taken to prevent recurrence, vii
For nuclear power plants, d:dicated groups have besn formed both by the NRC and by the nuclear power industry for the detailed review of operating experi-ence to help identify safety concerns early; to improve dissemination of such information; and to feed back the experience into licensing, regulations, and operations.
In addition, the NRC and the nuclear power industry have ongoing efforts to improve the operational data systems, which include not only the i
type and quality of reports required to be submitted, but also the methods used to analyze the data.
In order to more effectively collect, collate, store, re-trieve, and evaluate operational data, the information is maintained in computer-based data files.
l Two primary sources of operational data are Licensee Event Reports (LERs) and immediate notifications made pursuant to 10 CFR 50.72.
Except for records exempt from public disclosure by statute and/or regulation, information concerning reportable occurrences at facilities licensed or other-wise regulated by the NRC is routinely disseminated by the NRC to the nuclear industry, the public, and other interested groups as these events occur.
Dissemination includes special notifications to licensees and other affected or interested groups, and public announcements.
In addition, information on reportable events is routinely sent to the NRC's more than 100 local public document rooms throughout the United States and to the NRC Public Document Room in Washington, D.C.
The Congress is routinely kept informed of reportable events occurring in licensed facilities.
Another primary source of operational data is reports of reliability data submitted by licensees under the Nuclear Plant Reliability Data System (NPRDS).
The NPRDS is a voluntary, industry-supported system operated by the Institute of Nuclear Power Operations (INP0), a nuclear utility organization.
Both engi-neering and failure data are submitted by nuclear power plant licensees for specified plant components and systems.
The Commission considers the NPRDS to be a vital adjunct to the LER system for the collection, review, and feed-back of operational experience; therefore, the Commission periodically monitors the NPRDS reporting activities.
AGREEMENT STATES Section 274 of the Atomic Energy Act, as amended, authorizes the Commission to enter into agreements with States whereby the Commission relinquishes and the States assume regulatory authority over byproduct, source, and special nuclear materials (in quantities not capable of sustaining a chain reaction).
Agree-ment State programs must be comparable to and compatible with the Commission's program for such material.
Presently, information on reportable occurrences in Agreement State licensed activities is publicly available at the State level.
Certain information is also provided to the NRC under exchange of information provisions in the agreements.
In early 1977, the Commission determined that abnormal occurrences happening at f acilities of Agreement State licensees should be included in the quarterly reports to Congress.
The abnormal occurrence criteria included in Appendix A viii
are applied uniformly-to events at' NRC and Agreement State licensse facilities.
~
Procedures have been developed and implemented,'and abnormal occurrences reported-by the Agreement States to the NRC are included in these quarterly reports to Congress.
FOREIGN INFORMATION The NRC participates in an exchange of information with various' foreign govern-ments that have nuclear facilities.
This foreign information is reviewed and considered in the NRC's assessment of operating experience and in its research and regulatory activities.
Reference to foreign information may occasionally -
be made in these quarterly abnormal occurrence reports to Congress; however, only domestic abnormal occurrences are reported.
t ix
REPORT TO CONGRESS ON ABNORMAL OCCURRENCES DCTOBER-DECEMBER 1989 NUCLEAR POWER PLANTS The NRC is reviewing events reported at the nuclear power plants licensed to-oaerate.
For this report, the NRC has not determined that any events were.
abnormal occurrences.
FUEL CYCLE FACILITIES (Other Than Nuclear Power Plaats)
The FAC is reviewing events reported by these licensees.
For this report, the NRC aas not determined that any events were abnormal occurrences.
OTHER NRC LICENSEES (Industrial Radiographers, Medical Institutior.s, Industrial Users, etc.)
There are currently about 9,000 NRC nuclear material licenses in effect in.the United States, principally for use of radioisotopes in the medical', industrial,.
and academic fields.
Incidents were reported in-this category from licensees such as radiographers, medical institutions, and byproduct material users.
The NRC is reviewing events reported by these licensees.
For this report, the NRC~
has determined that the following events were abnormal occurrences:
89-13 Medical Diagnostic Misadministration The following information pertaining to this. event is also being reported con-currently in the Federal Register.
Appendix A (see the general criterion) of this report notes that an event involving a moderate or more severe impact on public health or safety can be considered an abnormal occurrence.
Date and Place - October 18, 1989; Mayo Foundation;= Rochester, Minnesota.
Nature and Probable Consequences - On October 27, 1989, the licensee reported to NRC Region III that on October 18, 1989, a patient received a diagnostic dose of a radioactive iodine compound that was 10 times the intended dose.
The referring physician intended that a patient receive a neck scan using 100 microcuries of iodine-131, but checked the box on the referral form indicating a scan using 1 millicurie of iodine-131.
The hospital reported that the patient 1
received an additional radiation exposure of about 1200 rem to the thyroid be-yond that intended by the referring physician.
Had the intended dose of 100 microcuries been administered, the thyroid would be expected to receive an exposure of no more than about 140 rem.
A medical consultant, retained by the NRC indicated that the added dose would result in a very slight increase in the risk that the patient could develop hypothyroidism or thyroid cancer.
The consultant recommended that the hospital monitor the patient with annual thyroid function tests.
Cause or causes - This misadministration occurred because the referring physi-cian checked the wrong box on the nuclear medicine referral sheet.
The nuclear medicine physician approved the neck scan procedure, but did not specify that it should be the neck scan with the lower dose of 100 nicrocuries (i.e., the nuclear medicine physician did not write the prescription on the order form).
Actions Taken to Prevent Recurrence Licensee - The hospital has revised its procedures to require additional precau -
tions for procedures involving greater than 20 microcuries of radioactive iodine.
Under the revised procedures, the nuclear medicine physician is to review the request for the diagnostic test and the patient's chart and not only approve the test but also write the prescribed dosage on the referral request form.
The hospital's radiopharmacy will not dispense any quantities of iodine greater than 20 microcuries without a properly prepared referral request form, which includes a prescription by a nuclear medicine physician.
NRC - A special inspection will be conducted at the hospital to review the incident and other aspects of the licensee's nuclear medicine program.
Unless new, significant information becomes available, this item is considered closed for the purposes of this report.
l 89-14 Medical Therapy Misadministration The following information pertaining to this event is also being reported con-currently in the Federal Register. Appendix A (see the general criterion) of this report notes that an event involving a moderate or more severe impact on public health or safety can be considered an abnormal occurrence.
Date and Place - November 30, 1989; Kuakini Medical Center; Honolulu, Hawaii.
Nature and Probable Consequences - On November 30, 1989, the licensee reported to the NRC that a medical therapy misadministration had taken place at its facility earlier that day when a therapeutic dose of 9 mil 11 curies of iodine-131 was inadvertently given to the wrong patient (Patient A rather than Patient B).
Patient A was intended to receive only a 20 millicurie diagnostic dose of technetium-99m MDP.
This dose was administered and the patient was seated in the waiting room pending a bone scan.
Meanwhile, Patient B arrived.
Patient B, who was scheduled to receive an iodine-131 hyperthyroidism treatment, completed an interview, signed a consent form, and was seated in the waiting room pending the iodine treatment.
2
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The technologist przpared a dose of 9 ail 11 curies of iodine-131 for administra-tion and reportedly called Patient B.
However, Patient A responded.
The tech-nologist explained the iodine-131 treatment, scheduled a follow-up appointment, and administered the dose to Patient A.
The patient then questioned the tech-nologist, and it became evident that the wrong patient had been treated.
Patient A was immediately informed of the error, and the patient's stomach was pumped, retrieving 3.2 mil 11 curies of the material.
The patient was then given potassium perchlorate and Lugol's solution to release any iodine-131 already trapped.in the thyroid and to block further uptake. The use rf Lugol's solution-continued for 14 diys.
This misadministration resulted in an estimated dose to the thyroid of from 560 to 820 rem. This dosage would result in a-very slight increase in the risk-that the patient could develop hypothyroidism or throat cancer.
The licensee plans to monitor the patient with annual thyroid function tests.
An NRC medical consultant reviewed the incident.
He concurred with the immediate actions taken by the licensee,-and with the licensee's planned corrective actions to prevent recurrence that are described below.
Cause or causes - The licensee stated that the misadministration was caused by human error on the part of the technologist and by inadequate procedural controls.
The root cause was due to inadequate supervision of activities.
Actions Taken to Prevent Recurrence Licensee - The licensee stated that: (1) a training class-has been scheduled for all technologists, (2) a single technologist will be required to handle all aspects of the iodine-131 therapy and must be able to recognize the correct patient prior to the treatment, and (3) the technologist, physician, and patient are required to concurrently sign the therapy worksheet prior to the administration.
NRC - An NRC inspection was performed on February 6-and 8, 1990.
No violations of license requirements were identified. The licensee's corrective actions to prevent recurrence were satisfactory.
Unless new, significant information becomes available, this item is considered closed for the purposes of this report.
AGREEMENT STATE LICENSEES Procedures have been developed for the Agreement States to screen unscheduled incidents or events using the same criteria as the NRC-(see Appendix A) and.
report the events to the NRC for inclusion in this report.
For this period, an Agreement State (Louisiana) reported the following abnormal occurrence to the NRC.
3
AS89-2 Irsdustrial Radiographer Overexpssure' Appendix A--(see Example 1 of "For All Licensees") of-this report notes that an exposure of the feet, ankles, hands, or forearms of-any individual to 375 rem j
or more of radiation can be considered an abnormal occurrence.
I Data and Place - August 26, 1989; Mobil-Lab, Inc. (the licensee) of Harvey, Loeiana, while performing industrial radiography at Shell Oil Refinery in Nw, Louisiana.
Nature and Probable Consequences - On August 26, 1989, the. licensee notified the Louisiana Department of Environment Qualit that earlier that day one of the licensee'y, Nuclear Energy Division (" Agency")
s radiographers had apparently received 1
a significant exposure to his left hand while performing radiography with a SPEC 2-T exposure device containing an 82 curie iridiur 192 sourco l
i The Agency performed an investigation on August 29, 1989, to determine the.
l circumstances associated with the incident.
This involved interviews with the 1
radiographer and the licensee, and a reenactment of the incident using a dummy The incident is briefly' described below.
source.
After performing an exposure, the radiographer cranked in the source, however, the source was not fully retracted into the exposure device.
The radiographer then performed an inadequate radiation survey that failed-to detect the exposed He locked the exposure device, took it to a piperack, and set the device j
source.
into a rack.
While preparing for the next exposure, he was located approximately
{
2 feet from the front of the exposure device in a squatting position,-with his back to the device.
After an estimated 8 minutes, he reached back, without turning around, and disconnected the source tube with his-left hand.
He pulled-the tube away and may have grazed the source capsule with his left palm.
i i
Within a couple of seconds, he noticed that the source was protruding from the nipple about 4 inches.
He immediately left the area and notified the lead radi-ographer.
The lead radiographer saw the exposed source, cranked it fully _into the exposure device, and then surveyed and locked the device.. After directing the radiographer to return to Hobil-Lab to turn in his TLD badge, he carried the exposure device to SPEC Inc., in Kenner,_ Louisiana, for inspection.
The exposure device appeared to be working properly.
The original calculated exposure was 3000 to 3500 rem.
Howevert this was revised downward to about 1400 rem, based on the Agency's investigation.
The whole-body exposure was about 12.9 rem, based on the reading of the radiographer's thermo-luminescent dosimeter (TLD).
The Agency advised the licensee to provide immed-late medical attention, including a doctor's examination of the hand and obtain-ing blood tests.
Though the calculated exposure of the radiographer's hand may have been as high as 1400 rom (as estimatea from an reenactment of the incident),
the hand showed no indications of injury.. Blood tests taken shortly after the incident, and again 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> later, were normal.
Cause or Causes - The Agency investigator concluded that the primary cause was the radiographer's failure to perform a proper radiation survey to determine if the source was in the safe position following a radiographic exposure.
No train-ing or significant management deficiencies were identified.
4
l Actions Taken to Prevent Recurrence Licensee - The licensee circulated a notice to its employees with their pay-checks; the notice described the incident and stated the cause was due to the-radiographer not performing a proper radiation survey.
In addition, the li-censee increased the number of field audits of radiography work being performed at job sites.
Agency - The licensee was cited fcr three violations: (1) failure of the radiog-rapher to perform a proper survey following an exposura, (b) permitting an indi-vidual to receive an exposure in excess of specified limits, and (c) permitting-the individual to act as a radiographer prior to the licensee's submission of proper forms to the Agency.
This item is considered closed for the purposes of this report.
l l
5 s
APPENDIX A ABNORMAL OCCURRENCE CRITERIA The following criteria for this report's abnormal occurrence determinations were set forth in an NRC policy statement published in the _ Federal Register on February 24, 1977 (Vol. 42, No. 37, pages 10950-10952).
An event will be considered an abnormal occurrence if it involves a major reduction in the degree of protection of the public health or safety.
Such an event would involve a moderate or more severe impact on the public health or safety and could include but need-not be limited to:
1.
Moderate exposure to, or release of, radioactive material licensed by or-otherwise regulated by the Commission; 2.
Major degradation of essential safety-related equipment; or 3.
Major deficiencies in design,-construction, use of, or management controls for licensed facilities or material.
Examples of the types of events that are evaluated in detail using these criteria are:
For All Licensees 1.
Exposure of the whole body of any individual to 25 rem or more'of radia-tion; exposure of the skin of the whole body of any individual to 150' rem or more of radiation; or exposure of the feet, ankles, hands or forearms of any individual to 375 rem or more of radiation [10 CFR 20.403(a)(1)],-
or equivalent exposures from internal sources.
2.
An exposure to an individual in an unrestricted area such that the whole body dose received exceeds 0.5 rem in one calendar year [10 CFR 20.105(a)].
3.
The release of radioactive material to an unrestricted area in concentra-tions which, if averaged over a period of 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />, exceed 500 times the regulatory limit of Appendix B, Table II, 10 CFR Part 20 [CFR 20.403(b)(2)].
4.
Radiation or contamination levels in excess of design values on packages, or loss of confinement of radioactive material such as (a) a radiation dose rate of 1000 mrem per hour three feet from the surface of a package containing the radioactive material, or (b) release of radioactive material from a package in amounts greater than the regulatory limit.
5.
Any loss of licensed material in such quantities and under such circum-stances that substantial hazard may result to persons in unrestricted areas.
6.
A substantiated case of actual or attempted theft or diversion of licensed material or sabotage of a facility.
7
7.
Any substantiated: loss of spCcial nucler material or any substantiated inventory discrepancy that is judged to e significant relative to normally expected performance and that is judged to da caused by theft or diversion or by substantial breakdown of the accountab,ity system.
8.
Any substantial breakdown of physical security or material control (i.e.,
access control, containment, or accountability systems) that significantly weakened the protection against theft, diversion, or sabotage.
9.
An accidental criticality. [10: CFR 70.52(a)].
i 10.
Amajordeficiencyindesign,. construction,oroperationhavingsafety implications requiring immediate remedial action.
11.
Serio':s deficiency in management or procedural controls in major areas.
12.
Series of events (where individual events are not of major importance),
recurring incidents, and incidents with implications for similar facilities (generic incidents) which create major safety concern.
1 For Commercial Nuclear Power Plants i
1.
Exceeding a safety limit of license technical specifications [10 CFR 59.36(c)).
2.
Major degradation of fuel integrity, primary coolant pressure boundary, or primary containment boundary.
3.
Loss of plant capability to perform essential safety functions such that a potential release of radioactivity in excess of 10 CFR Part 100 guide-lines could result from a postulated transient or accident (e.g., loss of emergency core cooling system, loss of control rod system).
4.
Discovery of a major condition not specifically considered in the safety analysis report (SAR) or technical specifications that requires immediate remedial action.
5.
Personnel error or procedural deficiencies that result in loss of plant capability to perform essential safety functions such-that a potential release of radioactivity in excess of 10 CFR Part 100 guidelines could result from a postulated transient or accident (e.g., loss of emergency core cooling system, loss of control rod system).
For Fuel Cycle Licensees 1.
A safety limit of license technical specifications is exceeded and a plant shutdown is required [10 CFR 50.36(c)].
2.
A major condition not specifically considered in the safety analysis report or technical specifications that requires immediate remedial action.
3.
An event that seriously compromised the ability of a confinement system to perform its designated function.
8
i APPENDIX B-UPDATE OF PREVIOUSLY REPORTED ABNORMAL NCURRENCES During the October through December 1989 period, NRC licensees, Agreement States, Agreement State licensees, and other involved parties, such as reactor vendors and architect-engineering firms, continued with the implementation of actions necessary to prevent recurrence of previously reported abnormal occurrences.
The referenced Congressional abnormal occurrence reports below provide the initial and any subsequent updating information on the abnormal occurrence discussed.
The updating provided generally covers events that-took place during the report:
period; some updating, however, is more current as indicated by the associated event dates.
Open items will be discussed in subsequent reports in the series.
NUCLEAR POWER PLANTS 79-3 Nuclear Accident at Three Mile Island This abnormal occurrence was originally reported in NUREG-0090, Vol. 2, No. 1,
" Report to Congress on Abnormal Occurrences:
January-March 1979," and updated in each subsequent report in this series (NUREG-0090, Vol. 2, No. 2 through Vol. 12, No. 3).
It is planned to continue these updates until defueling ac-tivities at the site are completed. The update of activities for this report period is as follows:
Reactor Vessel and Ex-Vessel Defueling Operations During the October through December 1989 period, approximately 13,800 pounds of fuel and debris were removed from the reactor vessel.
The total mass removed-from the reactor vessel as of the end of the period was approximately 296,800 pounds (about 99 percent out of a total of approximately 300,000 pounds of core
=
debris and other materials).
The majority of the remaining core debris is in-canisters in the reactor vessel, but hasn't been weighed or removed. ~ The ap-proximate 300,000 pound total mass to be removed included the mass of the core; structural and absorber materials; mass added by oxidation of core and structural material; and portions of the baffle plates, formers, and other components that have become commingled with core debris during defueling operations.
Defueling of the area between the core baffle plates and the core barrel was completed.
On December 16, 1989, fol?owing completion of pick and place defueling and vacuum defueling of the lower head, the licensee declared an end to bulk defueling.
Af ter the completion of bulk defueling, the licensee began a final " flush and brush" to remove a layer of fuel fines and other small debris which had col-lected on horizontal surfaces and in crevice areas.
The " flush and brush" will be followed by a video verification of the defueling effectiveness.
Decontamination and Dose Reduction Activities Since early December 1988, the licensee focused its ef forts on the completion of defueling and the support of that activity.
Decontamination (other than the reactor building) and system flushing attivities are currently suspended, except limited efforts to support defueling and to maintain access to and operability of plant systems.
-i 9
1 Fuel Cask Shipments During_the period, one additional shipment containing about 23,800 pounds of core debris was made from THI-2 to the Idaho National Engineering Laboratory (INEL).
The total amount shipped is about 290,600 pounds of core debris, which represents about 97 percent of the total to be shipped.
Proposal to Dispose of Accident-Generated Water The licensee began testing of the evaporator which will be used to dispose of-the accident generated water (AuW).
The initial testing has resulted in modi-fications and upgrades being made to the evaporator.
The licensee has been rerunning the tests following modifications which could affect the evaporator's performance.
It is expected that testing will be complete and evaporation of the AGW will begin in March or April of 1990, i
TMI-2 Advisory Panel Meetinas The next meeting of the Advisory Panel for the Decontamination of Three Mile Island Unit 2 (Panel) will be scheduled after the Panel members and the NRC staff receive the licensee's final defueling completion report (DCR).
The final DCR is expected to be issued in the first calendar quarter of 1990.
The Advisory Panel meeting will be scheduled for approximately a month later to allow the Panel members and public adequate time to study the DCR.
Future reports will made as appropriate.
A A A A A A A A i
10
APPENDIX C OTHER EVENTS OF INTEREST The following item.is described because it may possibly.be perceived by the pub-lic to be of public health or safety significance. The item did not involve a major reduction in the level of protection provided for public health or safety; therefore, it is not reportable as an abnormal occurrence.
1.
Significant Degradation of Reactor Fuel Rod Claddina at Haddam Neck On September 3, 1989, the Haddam Neck Plant (a Westinghouse-designed pressurized water reactor located in Middlesex County, Connecticut) was shut down for refuel-ing after 461 days of continuous operation.
Because fission product concentra-tions in the reactor coolant were higher than normal during the operating cycle, the licensee (Connecticut Yankee Atomic Power Company) conducted extensive.
examinations of the reactor fuel assemblies.
The licensee found damage to the stainless steel cladding of a significant number of fuel rods.
While there was no effect on public health or safety (which is discussed further below), the event is of particular interest because:
(1) a very large number of fuel rods was involved; (2) the unusual nature of the damage; and (3) the damage partially compromised one of the three fission product barriers common to nuclear power plants (i.e., fuel rod cladding, primary coolant pressure boundary, and primary containment boundary).
The details of the event are as follows.
The Haddam Neck reactor core is 10 feet long and consists of 157 fuel assemblies.
Each assembly is made up of a 15 by 15 array containing 204 fuel rods, 20 control rod thimbles and one incore instrument sheath.
The stainless steel fuel-clad is 16.5 mils. thick with an outer-diameter of 0.422 inch.
Iodine concentration in the reactor coolant, which is typically used to monitor fuel rod integrity during operation, indicated that a limited number of fuel rods (about six to twelve) had failed during the first few months of the operating cycle.
The iodine levels stabilized during the cycle 'and the iodine-131 activity at the end of the cycle averaged 0.025 microcurie per milliliter, about a factor of four higher than previous operating cycles.
Following reactor shutdown, the iodine-131 spiked to about 0.8 microcurie per milliliter.
During the subsequent cooldown and depressurization, the iodine-131 spiked to about 11.5 microcuries per milliliter.
In September 1989, the reactor core was unloaded to the spent fuel storage pool.
Ultrasonic examinations of the. fuel identified a total of about 450 failed fuel rods.
Of these failures, 343 were in 95 fuel assemblies intended for reuse in the next cycle. That number of failures far exceeded the anticipated failures.
Rod clad failure was confirmed with eddy current tests; the-failure rate was about 1.5% of the rods.within the core. The defects were generally pinhole sized, and primarily concentrated in the bottom 1.2 inches of the fuel rods.
The failures were caused by small, fingernail-sized metal chips or shavings that had accumulated in the region between the fuel assembly lower nozzle and the first fuel rod spacer grid.
Less than 0.2 cubic foot of debris were collected following cleaning efforts.
Long-term fretting between the debris and the adjacent fuel rods resulted in penetration of the fuel cladding.
11
1 Although the source of the debris has not been absolutely identified, it is be-lieved to be stainless steel chips which escaped the controls to capture them during machining operations associated with modifications to the reactor vessel thermal shield supports which were performed during the last refueling.
During that work, which was all performed remotely and under water, mechanical devices such as dams, trays, and water suction probes were used to catch tailings from end mill machines. Although extensive cleanup efforts were conducted, the li-censee did not flush the reactor coolant system to remove hidden debris prior to reactor coolant pump operation with an assembled reactor.
At present, eddy current inspections are being made of fuel rods believed to be defective following ultrasonic examination, along with rods at debris sites, rods adjacent to damaged rods and rods selected randomly.
A rod is rejected if found with a defect greater than 20% of wall thickness.
Rejections are occurring at the rate of about 11% for known debris and failure sites, and about 4% for the i
randomly selected rods.
The core also contained four test fuel assemblies of fuel rods clad with Zircaloy rather than stainless steel.
(The licensee plans to use cores with all fuel rods clad in Zircaloy sometime in the future.) There were no unacceptable defects found in the fuel rod cladding in these test as-semblies.
The Zircaloy cladding is considerably thicker than the cladding of the stainless steel assemblies (i.e., 27 mils vs. 16.5 mils).
Seventy-five per-cent of the damaged rods have been located in the outer two peripheral rows of the stainless steel clad fuel.
The licensee is replacing rejected rods with acceptable fuel rods from once-and twice-used fuel assemblies.
Each rod is inspected to be free of defects and has an accumulated power history similar to that of the damaged rod being replaced. The licensee is currently evaluating programs for the cleaning and flushing of reactor components and the reactor coolant system.
The fuel assem-blies have been mechanically cleaned of all visible debris.
Since donor fuel rods are being obtained from assemblies which would have been reused, the li-censee has ordered additional new assemblies.
Prior to plant startup, it will be necessary for the licensee to reevaluate the modified reload reactor core to verify that safety analyses inputs remain valid.
The NRC will closely monitor the actions taken by the licensee.
As previously mentioned, there was no effect from the event on public health or safety.
Although many fuel rods were affected, the release of radioactivity to the coolant was not very large, i.e., the coolant activity remained within the technical specification limitations.
Because of the location and the failure mode (pin-hole failures), damage to the fuel rods only partially compromised the fuel rod cladding barrier.
At all times, the releases offsite remained within the technical specification limits.
Based on these considerations, the event was considered below the threshold for an abnormal occurrence.
12
NRC 9onM 336 U S. NUCLEQQ GlQULM ORY COMMITS 10N L RtPORT NJMBt R t
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BIBLIOGRAPHIC DATA SHEET NUREG-0090
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Vol. 12 No. 4.
a.mte AHo susmtt Report to Congress on Abnormal Occurrences:
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October - December 1989 March 1990
- 4. F IN OR GR ANT NUMBE H tt AUlHOH(St 0 TYPLOFFiLPONI Quarterly L Pt HIOD COV E H L D isas Arsew Demer
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ae ne ennt moonne erewaI Office for Analysis and Evaluation of Operational Data U.S. Nuclear Regulatory Consnission Washington, E.C. 20555
- 9. SPONSORING ORGAN 12 ATION - NAM E AND ADDHLSS tit hac, ers= *se== m ecow ; er easineer, a<eva* **C De**a, O" vee or 8* pen, u.3 4weer Aevoserver Co*amewca.
s end awonne enkeress.I Same as 8., above
- 10. SUPPLEMENT ARY NOTES 11, ABST R ACI (200 weech er freef St: tion 208 of the Energy Reorganization Act of 1974 identifies an abnormal occur-rence as an unscheduled incident or event which the Nuclear Regulatory Commission determines to be significant from the standpoint of public health and safety r.nd requires a Quarterly report of such events to be made to Congress. This report covers the period October 1 through December 31, 1989. For this reporting period, there were three abnormal occurrences, none involving a licensed nuclear power plant. Two of the abnormal occurrences took place under other NRC-issued.licen-ses. The first involved a medical diagnostic misadministration and the second involved a meoical therapy misadministration. The third abnormal. occurrence was reported by an Agreement State (Louisiana) and involved an overexposure to an industrial radiographer. The report also contains informaion that updates e previously reported abnormal occurrence.
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- 83. AV A8k A8'LI T Y 51 A l' M*N 3 Medical Diagnostic and Therapy Misacministrations; Industrial jnlimited Radiographer Overexposure; Reactor Fuel Rod Cladding Degradation at Haddam Neck.
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