ML20085H345
| ML20085H345 | |
| Person / Time | |
|---|---|
| Site: | Calvert Cliffs  |
| Issue date: | 10/16/1991 |
| From: | Creel G BALTIMORE GAS & ELECTRIC CO. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| NUDOCS 9110280244 | |
| Download: ML20085H345 (4) | |
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-t-DALTIMORE i
GAS AND ELECTRIC CHARLES CENTER
- P.O. 00X 1475
- BALTIMORE, MARYLAND 21203-1476 GeoRoc C. CRtet 3lfd[",'l7/,",',
October 16,1991 130s) gen.4 o gg U. S. Nucicar Regulatory Commission Washington,DC 20555 ATTENTION:
Document Control Desk SUBJEC1':
Calvert Cliffs Nuclear Power Plant Unit Nos.1 & 2; Docket Nos. 50-317 & 50-318 B.csEms.r ta Si imritoj of Spent Fuel Pins Notice of"inlajion l
REFERENCE:
(a)
Letter from Mr. J. II. Joyner (NRC) to Mr. G. C. Creel (BG&E),
Combined Inspection Nos. 50-317/91 19; 50 318f>1-19, dated Sep*cmber 17,1991 Gentlemen:
In response to Reference (a), Attachment (1)is provided.
Should you have any farther questions regarding this matter, we will be pleased to discuss them with vou.-
Very truly yours, m
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Attachment ec:
D. A. Brune, Esquire -
J. E. Silberg, Esquire R. A. Capra, NRC D. G. Mcdonald, Jr., NRC T. T. Martin, NRC l
L E. Nicholson, NRC 3
l' R. I. McLean, DNR h
J. II. Walter, PSC
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SillPMENT OF SPENT FUEL PINS NOTICE OF VIOLATION COM HINED INSPECTION NOS. 50 317/91 19/ 50-318/91 19 I, -
J)ESCRILTiON ANI) CAUSE OF INENT, e
In May,1988, fuel seconstitution efforts were underway in the Calvert Cliffs Spent Fuel Pool during the Unit 1 EOC 9 refueling outage. Combustion Engineering (CE) was contracted by Baltimore Gas and Electric (BG&E) to perform reconstitution tasks, with oversight provided by BG&E. uc purpose of the reconstitution campaign was to repair assemblics identified as containing failed rods and to prepare a package (fuct assembly grid cage,12 fuel rods and a non.fucled rod) for shipment to a hot celllaboratory at Chalk River,in Ontario, Canada.
To perform the reconstitution, CE used Calvert Cliffs Fuel llandling Procedure Fil 48 -
which incorporated various CE procedures pert'ining to specific reconstitution tasks. %c process to prepare the package For shipant to the not ecil laboratory was as follows: The empty irradiated grid cage was obtained by removing and transferring 170 of the 176 fuel rods from fuel anembly 10003 into a new grid cage; Six fuel rods and a non-fueled rod were then Ltransferred from other assemblics into the irradiated grid cage; This yicided the desired package for shipmen' - the irradiated grid cage,12 fuel rods and a non. fueled rod.
Tbc irradiated grid cage and the attendant rods were eventually shipped to Chalk River in Se,..ctnber,1990. In July,1991, CE and UG&E were notified that an additional fuel rod had been discovered in k> cation C-5 within the irradiatcJ grid cage when the. package was removed from the shipping cask at the laboratory. Further inspection confirmed that this fuel rod was the fuel rod that had originally resided in k) cation C-5, and was one of the complement of 170 rods that was to have been removed during preparation of the package in -
May,1928.
A review of the procedure revealed that the ucp governing the rod transfer was signed off by CE, ndicating that the rod had been transferred when it, in fact, had not. Two additional ~
steps in the procedure were signed off by CE indicating that visual verifications of rod patterns within the grid cages had occurred. These sisual verifications were designed to catch g
the type of< n which had occurred.
The eff:ct of tt :rror was that an additional fuel rod was shipped to the hot cell facility, h
Therefore, the shipping manifest, prepared on the basis of an intended shipment of 12 fuel L
. rods and 1 non. fueled rod, was incorrect with rerpect to the activity level listed on the manifest.' Although the manifest was incorrect, there were no safety implications associa"d with the event. There was no inadvertent release of radioactivity to the public and no g
j overexposure to any individuals involved.'
i' The root cause of this event is that the vendor procedures incorporated into FH-48 did not provide adequate costrol for the process to preclude such an event.: The lack of specific direction for ts acking fuel rod movement and of adequate guidance for visual verification led to _the sign-off errors. Good practices and lessons learned from previous activitics had not been incorporated into the procedure. The procedure consequently did not provide a sufficient barrier to failure. BG&E oversight of vendor activitics was not sufficient to prevent or to catch the error. BO&E oversight was deficient in that it failed to identify and observe the key steps that would ensure the success of the activity.
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SillPMENT OF SPENT FUEL PINS NOTICE OF VIO1ATION COMillNED INSPECrlON NOS 50 317/91 19/ 50-318/91 19 In CORRECTIVE STEPS TAKEN AND RESIILTS AC1IIEVED.
Based on the discovery that an additional fuel rod had been shipped to the hot cell, the-following actions were taken:
The fuel rod accountability database was corrected to account for the shipment of the extra fuel rod.
A revised DOE /NRC Form 741 was issued to include the mass of the additional fuel rod and to also provide a more precise calculation of all Special Nuclear Material (SNM)- related isotopes.
The export license prepared by CE for the shipment is being revised to reflect the additional fuel rod and to provide a more precise calculation of all SNM-related isotopes.
A NETWORK entry, describing this event, was initiated to alert other utilities to the potential for similar events.
III.
CORRECrlVE STEPS WillCil WILL llE TAKEN TO AVOID FURTilER VIDIATIONS.
To prevent this type of event m the future, we are making changes to enhance our oversight of vendor activities, as well as requiring CE to make changes to their existing practices.
BG&E required CE to perform an internal root cause investigation et' their own activities.
CE and BG&E will work together to ensure that CE's procedures adequately control the process, and appropriately include lessons learned and good practices such that the procedures provide an appropriate barrier against failure. Examples of the types of
- mprovements to be made include requiring rod transfers to follow a specified pattern, requiring better decumentation of rod removal and rod insertion, and providing better guidance on ensuring that rods are, in fact, latched to the rod handling tool during transfers.
Verification ' of complete and accurate work is crucial to successfully completmg 3
reconstitution activities. The process for performing the visual verification of rort patterns will be examined to improve it such that it is easier to perform an adequate verification.
The ultimate responsibility for ensuring reconstitution activities are compicted without error rests with BG&E, The first step in ensuring success is to require contractors to use adequate procedures and practices. Verification of their adequacy is provided tlwough adequate oversight of their activities. BG&E oversight will be enhanced by determiniiig those steps in the process which are critical to success and monitoring the results achieved.
Additionally, BG&E will require that contractors continue to provide QC coverage for reconstitution activities that involve returning fuel to the core. For other reconstitution activities, the need for QC coverage will be evaluated.
The procedural changes and program enhancements will be completed prior to the next reconstitution campaign undertaken at Calvert Cliffs.
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- KQ'ACIIMENT f.D Sill!' MENT OF SI'ENT FUEL l' INS NOTICE OF VIOLATION COMHINEI) iNSI'ECI'lON NOS. 50 317/91 19/ 30-318/9I 19 IV.
DATE WilEN FUI,1,COJ]l'I,IANCE WAS ACIIIEVEI).
Full compliance was achieved when a new and correct manifest was submitted on August 28, 1991.
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