ML20135E982
| ML20135E982 | |
| Person / Time | |
|---|---|
| Site: | 07001201 |
| Issue date: | 11/27/1996 |
| From: | Elliott G FRAMATOME COGEMA FUELS (FORMERLY B&W FUEL CO.) |
| To: | Ting P NRC OFFICE OF NUCLEAR MATERIAL SAFETY & SAFEGUARDS (NMSS) |
| References | |
| CAL, NUDOCS 9612120285 | |
| Download: ML20135E982 (5) | |
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t F RAMATOME COG EM A F U E LS November 27,1996 Mr. Philip Ting, Chief Operations Branch Division of Fuel Cycle Safety & Safeguards United States Nuclear Regulatory Commission Washington, D.C. 20555
Dear Mr. Ting:
On November 13,1996, Framatome Ccgema Fuels (FCF) reported to the NRC that it was unable to account for an unirradiated fuel assembly which had been shipped to its Fuel Manufacturing Facilities in Lynchburg, Virginia. This led to NRC inspection l
Number 96-202. During the inspection, NRC requested the results of FCF's root cause investigation and corrective actions. The attachments to this letter provide the requested information. We believe the corrective actions taken will prevent similar events in the future. Corrective actions 1 through 3 will be completed prior to unloading of remaining transport packages. This will comply with the actions stated in your Confirmatory Action Letter.
Framatome Cogema Fuels personnel are available to meet with the Operations Branch or other members of the NRC staff to discuss the root cause and corrective actions and to answer any questions you may have on how our action plan will be implemented. We request a meeting as soon as practical after you have had a chance to review this submittal.
Should you have any questions regarding the attached information, please feel free to contact me at (804) 832-5202 or Charles W. Carr at (804) 832-5015.
FRAMATOME COGEMA FUELS Lynchburg Manufactu ng Facility
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f, am F. NW 9612120285 961127 PDR ADOCK 07001201 Manager, Safety & Licensing h
C PDR c:
Bruce S. Mallett - NRC Region ll j
Elizabeth Q. Ten Eyck - FCSS g
Carl A. Paperiello - NMSS M
Frematome Cogema Fuels F R AM ATO M E e o. eex 11646. Lynchburg, VA 24506 1646 TECHHOLOOIE5 Telephone: 804 832-5000 Fax: 804 832 5167
ATTACHMENT 1 Page 1 of 3 l
I BACKGROUND l
On November 13,1996, Framatome Cogema Fuels (FCF) reported to the NRC that l
It was unable to account for an unirradiated fuel assembly which had been shipped to its Fuel Manufacturing Facilities in Lynchburg, Virginia. The fuel assembly was one of 180 for which FCF had contracted to disassemble and download the pellets for reprocessing by another contractor.
The fuel assemblies to be downloaded were shipped from Greifswald, Germany. They were shipped in packages containing six assemblies per package. The container packages were shipped in groups of six per shipment so that typical individual shipments involved a total of 36 fuel assemblies.
Each assembly was wrapped in plastic and sealed in its separate cell of the container package. The containers in which the fuel assemblies were shipped to Lynchburg were returned to their origin with the packing material inside each cell of the container.
The shipment involving the temporarily lost fuel assembly was the second shipment In a total series of five to be accomplished.
Initially, upon the realization there was a discrepancy in the number of on-site fuel assemblies, this was believed to be a paperwork problem, but further searches confirmed that one fuel assembly was missing and believed to have been inadvertently left in the shipping container. This was subsequently confirmed when i
FCF requested that personnel at the assembly's origin inspect the returned container.
1 This event led to NRC Inspection Number 96-202. The information which follows summarizes the root cause investigation and corrective actions taken by FCF.
PROCESS FOR REMOVAL OF ASSEMBLY FROM TRANSPORT PACKAGE Bundle assemblies for download were received at Framatome Cogema Fuels in Model TE 440/70 transport packages. Each transport package was brought into the facility, up righted, and placed in the pit. The seal on each transport package was broken, placed in a bag and given to the Nuclear Materials Control organization for return to the shipper. The lids and gaskets were removed from each of the six (6) individual containments. The plastic was trimmed away from each assembly. The assembly serial numbers, located on the top edge of the end fitting, were verified against a Nuclear Materials Control supplied document. Each assembly was then removed from the transport package and stored in the assembly racks. Some of the radiological surveys were performed at this time. Upon completion of the surveys, the gaskets and lids were replaced on the empty transport package. The transport package was stored in the designated area where further radiological surveys were performed. The transport package was then available for return shipment.
This operation does not fall under the provisions of the routine manufacturing processes covered by the FCF Quality Program.
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ATTACHMENT 1
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Pcg3 2 of 3 i
ANALYSIS AND DETERMINATION OF ROOT CAUSE A Root Cause Investigation Team was established anc included members directly involved in the processes. Personnel involved on the team included representatives from the unloading process, Safety and Licensint), Shipping, Manufacturing Engineering and a neutral party.
The Root Cause Investigation Team reviewed in detail the unloading process from receipt of the tiansport packages in the sea vans through loading of the empty packages for return shipment. After the process was reviewed, a brainstorming session was held to identify all possible weaknesses in the process.
j During analysis and determination of the root cause, several contributing factors surfaced. The actions discussed here-in-after address the short term actions required to prevent recurrence and initiate actions to gather data on organizational performance which will lead to effective corrective actions in programmatic, management, and other areas which contributed to this incident. These contributing factors are being evaluated in accordance with the Corrective Action Plan.
ROOT CAUSE Key organizations failed to recognize the potential for leaving an unirradiated fuel assembly in the Model TE 440/70 transport package, therefore, procedures were not designed to address this possibility.
CORRECTIVE ACTION PLAN The corrective actions outlined below address both the root cause and other contributing factors.
1.
FCF Route Card Number 11876 (Attachment 2) will be implemented at transport receipt to follow each transport package through receipt, unloading and subsequent loading of each empty transport package for shipment. This will prevent recurrence and assure accountability for the following reasons:
Transport numbers, tamper seal numbers, and assembly serial numbers will be verified to the source packing list.
Location of each assembly, after unloading and storage, will be recorded.
l Product Quality will verify the serial numbers of the assemblies in the storage racks to the packing list.
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An operator other than the individual who unloaded the assemblies will verify each transport containment is empty.
ATTACHMENT 1
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f P g2 3 of 3 All radiation surveys and shipment records will be reviewed by a Health Physicist, qualified in DOT regulations, prior to release of the transport.
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Transport packages will be weighed prior to return shipment to verify that no assemblies are present.
The Route Card will be implemented upon completion of the NRC review.
2.
Training on the revised process, in accordance with the attached Route Card, will be performed and documented prior to unloading of remaining transports.
This will be performed upon completion of the NRC review and as part of implementation.
3.
Radiological surveys and shipments will be reviewed and approved by a Health Physicist, trained in DOT regulations, prior to release of all shipments.
Action implemented November 20,1996.
4.
A self-assessment will be performed on FCF practices for shipping and receiving radioactive materials. Actions indicated from this assessment will be established.
Assessment will be complete by January 31,1997.
5.
An assessment by an independent organization will be performed on FCF practices for shipping and receiving radioactive materials. Actions indicated from this assessment will be established.
Assessment will be complete by March 31,1997.
6.
All storage rack locations will be coded and the racks will be posted with a document which records what VVER Fuel Assembly is in each location. A regular inventory will be performed by Nuclear Materials Control.
Complete by December 6,1996.
I 7.
Plant management practice (s) for overview of unique or first-of-a-kind activities with respect to the use of existing or standard practices will be reviewed and revised as necessary to assure better oversight.
Complete by April 1,1997.
8.
General Employee Training on handling Special Nuclear Materials including safety and accountability will be reviewed to assure adequate sensitivity exists.
Complete by December 31,1996.
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7019334 P.O. Box 11646
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4 Mr. Philip Ting, Chief Operations Branch Division of Fuel Cycle Safety & Safeguards United States Nuclear Regulatory Commission Washington,D.C. 20555 s
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