ML20149G707

Pre-Decisional Enforcement Conference Rept 70-1151/97-204 on 970709.Major Areas Discussed:Five Apparent Violations Noted in Insp Rept

ML20149G707
Person / Time
Site:	Westinghouse
Issue date:	07/09/1997
From:	NRC OFFICE OF NUCLEAR MATERIAL SAFETY & SAFEGUARDS (NMSS)
To:
Shared Package
ML20149G706	List: ML20149G704 ML20149G707
References
70-1151-97-203, NUDOCS 9707240026
Download: ML20149G707 (43)

Text

. . . _ _ . - .- .. .- . - -- - - - . - - - - .

r,1 p.

1 is j

{ .

,. U. S. NUCLEAR REGULATORY COMMISSION

'. OFFICE OF NUCLEAR MATERIAL SAFETY AND SAFEGUARDS

Report No. . 70-1151/97-204 L -

1-

. License No. SNM-1107 J

a '

j- Docket No. 70-1151.

. Safeguards Group

- III 1 .-

Licensee: Westinghouse Electric Corporation

- Commercial Nuclear Fuel Division Columbia, SC 29250-t.

Pre-Decisional Enforcement Conference Conducted at: Rockville, MD

+

I P. nal Enforcement Conference Conducted on'  : July 9,1997 i

Prepared by: 4 D. Whaley, MC&A Physical Scientist Approved by:. Philip Ting ~, Chief Operations Branch Division of Fuel Cycle Safety and Safeguards, NMSS I

l l

Enclosure 1 9707240026 970718 i PDR ADOCK 07001151' .

C PM ,

u ,, _ _ .. ; . , . .

g a 2

i EXECUTIVE

SUMMARY

Westinghouse Electric Corporation Predecisional Enforcement Conference Report On July 9,1997, a predecisional enforcement conference was held at NRC Headquarters, Rockville, Maryland, to discuss five apparent violations identified in Inspection Report No. 70-1151/97-203. The conference provided an opportunity for Westinghouse Commercial Nuclear Fuel Division to discuss the five apparent violations and to provide corrective and preventive actions. The licensee acknowledged the five violations cited. The licensee described the corrective actions undertaken to correct the items of non-compliance, and application of lessons learned to prevent similar violations from occurring in the future (see Enclosure 2).

In the opening statement, the Director of the Division of Fuel Cycle Safety and Safeguards stated the reasons for the predecisional enforcement conference as it related to the inadvertent shipment of two unirradiated fuel rods to the Temelin Plant in the Czech Repub.lic. The Director r:xplained that this meeting would provide Westinghouse Commercial Nuclear Fuel Division the opportunity to discuss the events surrounding the apparent violations identified during the May 5 - 7,1997, Special Inspection Team inspection; to acknowledge or deny the apparent violations; and to provide identification and correction of root causes for such apparent violations. The NRC primary concern was the programmatic issues, the lessons to be learned and the application of those lessons throughout the Westinghouse operation so as to prevent the occurrence of the same or similar events at the facility.

The NRC Enforcement Coordinator summarized the NRC's Enforcement "oiicy concerning the fuel rods. The discussion included the purpose of the predecisional enforcement conference and the enforcement process before the NRC makes the final enforcement decision for this event. In addition, the Enforcement Coordinator pointed out a minor error in the inspection report.

Specifically, all references in the inspection report relating to 10 CFR 20.2201 (a)(ii) should have been 10 CFR 20.2201 (a)(1)(ii).

The Director discussed the five apparent violations identified in the Inspection Report which included:

1) The licensee failed to implement proper notification procedures of the event to the NRC;

2) The licensee failed to provide adequate training and documentation of training;

3

3) The licensee failed to provide adequate and detailed procedures for the rod handling operation.

4) The licensee failed to comply with numerous requirements for the shipment oflicensed material; and

5) The licensee failed to implement adequate MC&A procedures and practices to verify the presence of the fuel rods.

The licensee was in basic agreement with all five violations. The licensce stated, however, that the violations presented no safety threat or danger to the public, the workers at the Columbia Fuel Fabrication Facility, the Temelin Plant in the Czech Republic or the environment.

The licensee discussed its perspective of the event beginning with a review of the incident. The presentation included the results of the root cause analysis and provided a detailed review of the iausal factors and corrective actions already planned and completed. The internal investigation essentially agreed with the NRC inspection Report and stated that the Westinghouse organization understood the seriousness of this event and is committed to correcting the conditions and practices that allowed the event to occur. Westinghouse management understood its responsibility for this event and acknowledged the need for strengthening and maintaining proactive management oversight and involvement in the area of Material Control and Accounting at the Columbia Plant.

The licensee stated that, based on the NRC's Enforcement Policy (NUREG 1600), the collective violations should be no greater than Severity Level 111 and a civil penalty, if any, should be mitigated. The mitigation presented by the licensee included:

1) The violations were self-identified without an " event" occurring;

2) Comprehensive and effective corrective actions are in place to prevent recurrence and similar occurrences; and

3) The Columbia Plant has a long history of sustained, positive performance and regulatory compliance.

The meeting was adjourned.

l i

.,1 . .; ,

4

< Attendees Westinohouse Commercial Nuclear Fuel D~ vision L~. Campagna, Westingho'use, Assistant Generai Counsel J. Fici, General Manager, Commercial Nuclear Fuel Division -

' D. Goldbach, Westinghouse, Manager, IFBA and Fuel Rod Operation W. Goodwin, Westinghouse, Manager, Regulatory Affairs J. Ifeath, Westinghouse, Manager, Regulatory Engineering and Operations E. Keelen, Westinghouse, Product Assurance -

R. Williams, Westinghouse, Advisory Engineer Regulatory Affairs NRC B. Brach, Deputy Director, Fuel Cycle Safety and Safeguards

.Y. Chen, Chemical Engineer, Fuel Cycle Operations Branch E. Easton, Branch Chief, Spent Fuel Project Office

- R. Iloefling, Office of General Council N. Mamish, Enforcement Coordinator, Nuclear Material Safety and Safeguards E. McAlpine, Branch Chief, Region II

_--W. Schwink, Section Chief, Fuel Cycle Operations Branch

- E. Ten Tyck, Director, Fuel Cycle Safety and Safeguards P. Ting, Branch Chief, Fuel Cycle Operations Branch  !

! .W. Troskoski , Sr. Chemical Engineer, Fuel Cycle Operations Branch M. Weber, Branch Chief, Licensing Branch i

D. Whaley, Physical Scientist, Fuel Cycle Operations Branch 1

l i

1

+

, w .

• '-m--- E, n s a w - n - w sm 1 0

=

4 ENFORCEMENT CONFERENCE SLIDES 1

f Enclosure 2

-l

. j

m

.b o

' APPARENT VIOLATIONS

'A. 10 CFR 74.11 requires, in part, that the licensee notify the NRC Operations Center within one hour of discovery of any loss or theft or other unlawful diversion of SNM which the licensee is licensed to possess.

Licensee Condition SG-1.1 states, in part, that the licensee chall follow Chapters 1.0 through 9.0 of its " Fundamental Nuclear Material Control (FNMC) Plan."

Section 2.2.2 of the licensee's FNMC Plan requires, in part, that after resolving item and/or material control anomalies, Columbia Plant Manager, within 30 days or less, submit initial written report to the NRC.

10 CFR 20.2201(a)(1)(ii) requires, in part, that the licensee provide a telephone report within 30 days after the occurrence of any lost, stolen, or missing licensed material becomes known to the licensee, all licensed materialin a quantity greater than 10 times the quantity specified in Appendix C [0.01 Ci] to part 20 that is still missing at this time.

Contrary to the above, the licensee failed to properly implement its internal investigation and notification procedures. As a result, a telephone report to the NRC Operations Center was not made within one hour of the discovery of the loss of two fuel rods bearing SNM. In addition, a written report was not issued within 30 days after the lost material became known, November 20,1997, as required by 10 CFR Parts 20 and 74. Furthermore, the licensee did not notify NRC within 5 working days of the results of the initialinvestigation, as required by the FNMCP and implementing procedures, and the licensee did not notify the NRC of the suspected export shipment until 5 days after notification of the Temlin nuclear power plant personnel in the Czech Republic.

B. License Condition Number (No.) S-1 of License No. SNM21107 requires that licensed materials be used in accordance with statements, representations, and conditions in the license's License Application dated April 30,1995 and supplements thereto.

Chapter 2, Paragraph 2.1.2 of the License Application requires, in part, that, first level managers are also responsible for assuring that personnel under their jurisdiction receive adequate training.

Chapter 3, Paragraph 3.4.2 of the License Application requires, in part, that

" training will be provided for every individual in the Columbia Fuel Fabrication Facility (CFFF), commensurate with their duties. Formal training programs will be developed and implemented to enhance and augment procedure review and acknowledgement described in Paragraph 3.4.1(d) of this Chapter, and training responsibilities described in Chapter 2.0 of this License Application. Training records will be maintained in accordance with Section 3.8 of this Chapter."

1 The apparent violations discussed at this conference are subject to further review and change by the NRC prior to any resulting enforcement action.

I Contrary to the above, the licensee's training program was inadequate in assuring

. that CFFF personnel were properly trained and qualified for handling SNM in that: l

1. The MSA First Level Manager did not assure that MSA personnel received proper training with regard to the use of operating procedure MOP, 759006, ADU Fuel Rod Staging Area instructions, and implementation of the 7-day report requirements.

2. The formal training program did not document what training the MSA received in order for that individual to qualify for the position.

3. The performance of the MSA First Level Manager indicates that the training and qualification program was not effective in assuring that licensee personnel had an adequate understanding of the duties and responsibilities of the position, as evidenced by the failure to:

(a) routinely review and assure proper disposition of items listed in the 7-day report from October 1996 through January 1997; and once notified of the listed item, to disposition it in a timely manner or

) (b) promptly notify the Safeguards Coordinator.

C. License Condition Number (No.) S-1 of License No. SNM-1107 requires that licensed materials be used in accordance with statements, representations, and conditions in the license's License Application dated April 30,1995 and supplements thereto.

Chapter 3, Section 3.4.1 of the License Application requires that operations to assuro safe, compliant activities involving nuclear material will be conducted in accordance with approved procedures. Section 3.4.1(a.3) requires that the salient l utility of Category-3 Procedures will be to provide training and instructions, l including health, safety, and safeguards, for the Operations, Maintenance, l Inspection, and Analytical Services Functions. '

Contrary to the above, the licensee's program for generation, review, and approval of procedures was inadequate in assuring that Special Routings for non-routine activities were adequate to assure that the operation could be performed in a safe l and compliant manner. Specifically, Special Routing 13382, implemented on i October 5,1996, was inadequate in that it lacked many of the instructions for the opciation of the various equipment stations that were required by the routine Mechanical Operating Procedures for those stations; it referenced other Quality Control Instruction procedures that could not be followed for the planned operation; and the review and approval process failed to identify that the procedure could not  !

be followed as written, j i

l

% 6 l

l D. 10 CFR 71.5(a) requires that a licensee who transports licensed material outside of the site of usage, as specified in the NRC license, or where transport is on public highways, or who delivers licensed material to a carrier for transpnrt, comply with the applicable requirements of the regulations appropriate to the mode of transport of the Department of Transportation (DOT) in 49 CFR Parts 171 through 189.

49 CFR 171.2(a) prohibits any person from offering hazardous material for transportation unless, among other requiremen(s, the hazardous materialis properly classified, described, packaged, marked, labeled, and in condition for shipment required or authorized under the Hazardous Material Regulations (49 CFR Parts 171-177).

10 CFR 110.5 prohibits the export of special nuclear material (SNM), including unirradiated fuel, unless authorized by a general or specific license issued under Part 110.

10 CFR 71.12(a) issues a general license to any licensee of the Commission to transport, or deliver to a carrier for transport, licensed materialin a package for which a license, Certificate of Compliance (CoC), or other approval has been issued by the NRC.10 CFR 71.12(c)(2) requires the licensee to comply to the terms and conditions of the NRC CoC and the applicable requirements of subparts A, G, and H of this part.

NRC CoC, No. 9239, Rev. 4, dated March 21,1996, requires that the minimum transport index (TI) for a shipment of material in the licensee's shipping containers designated as MCC-3, MCC-4, or MCC-5, be shown on the shipping label for nuclear criticality safety as 0.4.

I Contrary to the above, on October 10,1996, the licensee inadvertently shipped a j two unirradiated fuel rods from their site in Columbia, South Carolina, to an overseas location, the Temelin Plant in the Czech Republic, and the licensee failed to comply with the transportation requirements for the shipment of licensed  ;

material specified in 10 CFR 71.5 and 49 CFR 170 through 189 in that:

1. The shipment of transport container No. M508 was classed as I non-hazardous; however, two unirradiated fuel rods which contained hazardous material were present, which was a violation of 49 CFR 171.2(a);

2. The shipment of transport container No. M508 failed to comply with several DOT hazard communication requirements, including those for shipping papers [49 CFR 172.200(a)] in that it f ailed to describe the hazardous material, marking [49 CFR 172.301(a)) in that it failed to mark the package l with the proper shipping name and identification number, and labeling 149 CFR 172.403(a)) in that it f ailed to label the package in accordance with the requirements;

- ?. o

3. The shipment of transport container No. M508 resulted in the export of two

. unirradiated fuel rods, a quantity that requires an NRC specific license under 10 CFR 110.5. The licensee used NRC License No. XCOM1082 rather than NRC License No. XSNM02785, which authorizes the export of a specified amount of SNM; and

4. The shipment of transport container (designated MCC-5) No. M508 did not comply with the terms and conditions of NRC CoC Number 9239.

Specifically, transport container No. M508 did not indicate a minimum transportation index of 0.4 on the label for critica!ity safety as required by the CoC.

E. Licensee Condition SG-1.1 states, in part, that the licensee shall follow Chapters 1.0 through 9.0 of its " Fundamental Nuclear Material Control (FNMC) Plan."

10 CFR 74.31 requires the licensee's material control and accounting (MC&A) system to confirm the presence of special nuclear material (SNM).

10 CFR 74.31(c)(6) requires, in part, that the licensees maintain current knowledge of items when the sum of the time of existence of an item, the time to make a record of the item, and the time necessary to locate the item exceeds 14 days, and also store and handle, or subsequently measure, items in a manner so that unauthorized removals of items will be detected.

Section 6.2 of the licensee's FNMC Plan requires that the licensee maintains control of items and verifies material shipment and removal from the item control program.

Licensee's Critical MC&A Procedure NMM-CP-630, "Special Nuclear Material item l I

Control," stipulates that all receipts, internal transfers, storage, and shipments of SNM shall comply with the item control provisions stated in the procedure.

Licensee's Regulatory Affairs Procedure RA-102, " Regulatory Compliance inspections - Columbia Site," requires that Regulatory Affairs personnel shall conduct, in part, routine inspections of SNM Safeguards requirernents during the course of their normal activities at least monthly.

10 CFR 74.15(a) requires, in part, that each licensee who receives and ships SNM shall complete a Nuclear Material Transaction Report (DOE /NRC Form 741) in accordance with instructions in NUREG/BR-0006, " Instructions for Completing Nuclear Material Transaction Reports and Concise Note Forms." Critical MC&A Procedure NMM-CP-650, " Nuclear Material Shipments," stipulates that all SNM shipped from the Columbia plant shall be measured or received a measurement verification before departing the plant site, and DOE /NRC Form 741 with shipper's values must be completed by the assigned porsonnel within one day of the shipment.

t.

l

?. . a: ,

.y Contrary to'the above/ the licensee's MC&A program was inadequately )

• implemented in that the first general performance objective of 10 CFR Part 74.31  !

was not met. The item control program failed to confirm the presence of two fuel i rods from October 5,' 1996 through April 17,1997. In addition, the licensee failed i

Sto maintain a current knowledge of items or make appropriate records when the. )

items could not be located within 14 days. As a resu!t of the loss of item control,  ;

i required DOE /NRC Form 741s were not generated.

• e 4

31 J

4-f 4

1 6

b I

P r

r

- , --- - . ,.w - w

SUMMARY

OF EVENT

~

• OCTOBER 5,1996 TWO FUEL (URANIUM BEARING) RODS

.CO-MINGLED WITH LEAD-FILLED RODS

• OCTOBER 10,1996, TWO FUEL RODS INADVERTENTLY SHIPPED TO THE CZECH REPUBLIC

• OCTOBER 16,1996, THE TWO FUEL RODS BEGAN APPEARING ON 7-DAY REPORT i

e MARCH 21,1997, SAFEGUARDS COORDINATOR NOTIFIED OF MISSING RODS j

• APRIL 10,1997, TEMELIN PLANT IN CZECH REPUBLIC

NOTIFIED OF POSSIBLE INADVERTENT SHIPMENT

• APRIL 15,1997, NRC NOTIFIED OF MISSING RODS

• April 17 & 18,1997, RODS LOCATED AT TEMELIN PLANT i

AND NRC NOTIFIED EACH DAY APPARENT VIOLATIONS'

~

I) THE LICENSEE FAILED TO IMPLEMENT PROPER NOTIFICATION PROCEDURES OF THE EVENT TO THE NRC.

. II) THE LICENSEE FAILED TO PROVIDE ADEQUATE TRAINING AND DOCUMENTATION OF TRAINING .

[

III) THE LICENSEE FAILED TO PROVIDE ADEQUATE AND DETAILED PROCEDURES FOR THE ROD HAND' LING OPERATION.

IV) THE LICENSEE FAILED TO COMPLY WITH NUMEROUS REQUIREMENTS FOR THE SHIPMENT OF LICENSED MATERIAL.

i V) THE LICENSEE FAILED TO IMPLEMENT ADEQUATE MC&A PROCEDURES AND PRACTICES TO VERIFY THE PRESENCE OF THE FUEL RODS.

• The apparent violations discussed at this conference are

! srbject to further review and change by the NRC prior to any resulting enforcement action.

i PREDECISIONAL ENFORCEMENT CONFERENCE AGENDA WESTINGHOUSE COMMERCIAL NUCLEAR FUEL DIVISION July 9,1997 at 1:00 pm NRC Headquarters, Rockville, Maryland

. l. OPENING REMARKS AND INTRODUCTION (

Elizabeth Q. Ten Eyck, Director Division of Fuel Cycle Safety and Safeguards, NMSS II. NRC ENFORCEMENT POLICY  !

Nader Mamish, Enforcement Coordinator, NMSS )

1.

f 111. -

SUMMARY

OF ISSUES STATEMENT OF CONCERNS / APPARENT VIOLATIONS Elizabeth Q. Ten Eyck, Director 2

Division of Fuel Cycle Safety and Safeguards, NMSS IV. LICENSEE PRESENTATION Jim Fici, General Manager ,

Westinghouse Commercial Nuclear Fuel Division j l Ed Keelen, Product Assurance Manager Westinghouse Columbia Fuel Fabrication Facility  !

V. BREAK / NRC CAUCUS a

VI. NRC FOLLOW UP QUESTIONS Vll. CLOSING REMARKS Elizabeth Q. Ten Eyck, Director Division of Fuel Cule Safety and Safeguards, NMSS 4

f a

E. *- d .p ' y

, M ? ~T4j* . -

i 1

nAc ;  ;

e n E

?$

WESTINGHOUSEELECTRIC CORPORATION

. Iw i COMMERCIAL NUCLEAR FUEL DIVIS(ON i

if COLUMBIA, SC FUEL FABRICA TION FACILITY f$$%

> SNM-1107/70-1151 f .

~

PRESENTATION TO THE U. S. NUCLEAR REGULA TORY COMMISSION I PREDECISIONAL ENFORCEMENT CONFERENCE l REGARDING NRCINSPECTION REPORTNO. 70-1151/97-203 July 9,1997 9

y I .. _. _ , _ . .,

?

ENDA  :

~ -...

...s. ,, < ~ . . ..

fuctory Remarks J. A. Fici puition on Findings ofApparent Violations __WCNFD Gen. Mgr,

! 'bh Significance ofIncident 1

,mem equence ofEvents E. E. Keelen l -

LActions to Recoverthe Two FuelRods WCFFFMgr. of

^ Opportunities forEarlierIdentification ProductAssurance 0Self-Identification Aspects a

) Root Cause Investigation and Causal Factors n

n?t1.

3; , Corrective Actions n ' dMitigation Factors and Discretionary Considerations J. A. Fici ni lSummaryand Conclusions 4

e i

fh,k. .

n Eifl FY}

9 l

t TRODUCTORYREMARKS

, a Westinghouse Electric Corporation (W)Is Here to Discuss the Incident Involving the Loss of Current Knowledge ofthe Location ye of Two Uranium Bearing FuelRods (FuelRods).

. eigt?%m w w'

.R: n NRCIR No. 70-1151/97 ?O3 Documents the NRC's Five Apparent Violations Which We WillAddress.

3 a

l n Our Overall Understanding of the Incident and Our Commitment Q4 as an NRC Licensee Are Addressedin OurPresentation.

p.

t

! d; l $

~

a

- .;\

i

g. m m ee w. e =

f RODUCTORYREMARKS (Cont'd)

Regarding the Incident, W Understands:

9

• The Seriousness of the Incident involving Loss of Current

. gf% ;d Knowledge ofthe Location ofLicensedMaterial, as Evidencedby:

- The Investigative Efforts and Corrective Actions Taken by CFFF

__W Executive Management's Commissioning ofan Independent 3

Management Oversight Team to Ensure an Effective ,

1 Investigation anda Comprehensive Corrective Action Plan wdQ y

e t

q

• Our Management Responsibility for the Incident py

• The Need for Strengthening and Maintaining Proactive Management Oversight andInvolvementin the Area ofMaterial

\Q}

y Controland Accounting (MC&A) at the Columbia Plant (CFFF) m%

., ?

• Our Obligation forPrompt, Comprehensive andEffective Corrective Actions in Response to the Incident.

1 l

. ,,,,,,,1... .

t RODUCTORYREMARKS (Cont'd)

WRemains Strongly Committed to

• The Health & Safety ofthe Public

5 '

gren.$

awa l

sy ya

• The Health & Safety of Employees at CFFFand Our Customers' Employees y

s .

• Protection ofthe Environment

,d dell

%. .

• Proactive Total Quality Management of Our Business t

%u .

• ManagementResponsibilityfor: .

l - MaterialControland Accounting

,x - Involvement / Oversight OverAllAspects ofOperations at CFFF p

P@

~

i

• On-Going Regulatory Compliance.

$Il

~

1 ti 00 TMMg pD .g p

OSITION ONNRC'S FINDINGS OF ARENT VIOLA TIONS '

. . . ~.

NRCInspection Report No. 70-1151/97-203, DatedJune 25, 1997, Documents NRC's Findings ofFive Apparent Violations:

i w

y;;f,~ *1. Failure to Implement ProperNotification Procedures  ;

'"*^^)

2. Failure to Provide Adequate Training

3. Failure to Provide Adequate Procedures for Lead-FilledRods 1 4. Failure to Comply with Shipping Requirements / Commitments

5. Failure to Implement Adequate MC&A Procedures and Practices.

%)

& n W's Position Regarding the Apparent Violations is that the NRC i l

Observations and Findings Mirror the Result of Our Root Cause Investigation; and We are in Basic Agreement with the Apparent  ;

1

, Violations as Presentedin the Inspection Report.

h-n 7 ~

Our Prompt and Comprehensive Corrective Actions Taken in Response Shouldbe Consideredin the NRC's Enforcement .

_ li[' Decision.

p l .. . _ _ __ _. . -

l ETYSIGNIFICANCE '

EVENT i

.s - -

6 # - . - . _ .5. -

. s . -

! n At No Time Did the FuelRods Pose Any Threat or Danger to the Health and Safety ofthe Public, CFFFEmployees or Temelin

e Plant Personnel, or to the Environment, Eitherin the Course of C.e Packaging and Transport, or During Storage at the Temelin i WW

.. p {, Plant Site:

3

• AH Uranium was in the Form ofCeramic PeHets.

s

• The PeHets were HermeticaHy Sealedin Only Two FuelRods.

Y \l

• The Two FuelRods were Shieldedby 310 Lead-FiMedRods m a

" Replica"FuelAssembly. ,

,,l ~

• The Two FuelRods were TransportedInside the " Replica" Assembly.

• The Two FuelRods were Transportedin an NRC/DOTApproved

)3 Shipping Package.

• The Two FuelRods were Securedat AH Times at the Temelin Plant b> Site.

t

?

The Two FuelRods HadLowRadiation Dose Levels (<0.5mr/hr).

W

• The TotalMass of U-235 was SignificantlyLess Than a CriticalMass.

p *s --. . - . .

ETYSIGNIFICANCE

• EVENT (Cont'd)

The Incident Did, However, Identify Certain Work Practices, Procedural and Training Inadequacies and Management i ' J Practices at CFFF, including Those for Non-Uranium Bearing l , Material, Which Could, IfNot Corrected, Have a Potentialfor W)?,**

Safety Consequences in the Future.

na Ad p;

,L0 n

6 _, m m ., p. , _

+

QUENCE OFEVENTS

_ _ . . ~ . _ - - _ . . . - . .

_~

9 O/96 A SpecialRouting was Originatedto CoverProcessing ofthe CZAB-70 Lead-FilledRods for Two Temelin " Replica" Assemblies.

~0)O4/96 Uranium Bearing FuelRods CZAF-70 were Being Processed Through

' MMMA Ultrasonic Tester, UT#1. The Two FuelRods in Question were Sent Down the

' i?'??} Reject Ramp ofUT#1 at 1900 Hours and Remained There Overnight.

3 10/05/96 CFFF QC Inspectors Arrived to Process the Non-Uranium Bearing Lead-Filled 1 Rods. UT#1 Sensor was Activated "On"to SendAllRods Onto the Reject Ramp. The Two FuelRods Which were on the Reject Ramp From the g}i} Previous Day were not Separated from the Lead-FilledRods and were J; . Inadvertently Placedinto the Same Cart As the Accepted Lead-Filled Rods.

10/08/96 Unknowingly, the Two FuelRods were Loadedinto One ofthe Two " Replica" 4 Assemblies with the Lead-FilledRods. i 1

'51

$ 10/10/96 The Two " Replica" Assemblies were Shipped to the Temelin Plant Site in the

$ Czech Republic in ContainerM508 in a Non-Uranium Bearing Package W . (Although One " Replica" Assembly Unknowingly Contained the Two Fuel Rods).

d T ff% #4 "'P P*...I ^

g

e UENCE OFEVENTS (Cont'd) 1

..~..,_..---2 v

- -- a . -. ,. ; 2: - , .. _ . -. .. . - - .- . - ,- - .

16/96 The First "7-Day Report" was issued Which Included the Two FuelRods in Question, but was Not Acted Upon by the Responsible Material Service Attendant (MSA #2).

f 4 g, f10/16/96- Weekly "7-Day Reports" Listing the Two FuelRods were issuedbut Not i/ ~[Of/24/97 DispositionedbyMSA #2(i.e., Location ofthe FuelRods was Not

'e Verified), nor Did the MSA Team Manager Require that the Location of  :

the Two FuelRods Be Verified.

e n

a

'i 01/24/97 MSA #1 Expressed Concern that the "7-DayReport"Had Too Many Fuel  ;

_)

xaA; Rods on it; this was Discussedat a Routine StaffMeeting.

^

l 01/27/97 The MSA Team Manager Discussed the "7-Day Report" With MSA #2 and i

Asked Him to Resolve the Report by April 1, Prior to the AnnualSNM PhysicalInventory.

fM 01/27/97- Periodic Meetings were Heldby the MSA Team Manager with MSA #2 to

?l ,

03/19/97 ReviewProgress.

p -

hk 03/20/97 A t a Plantwide SNM PhysicalInventory Meeting, it was Discussed that We Might Not Have Current Knowledge ofthe Location of the Two Fuel

~

V*l n Rods in Question.

- ,--,n .. -

UENCE OFEVENTS (Cont'd) ,

/21/97 The CFFFSafeguards Coordinator was noUfied ofthe Loss of Current Knowledge ofthe Location ofthe Two FuelRods.

{

03/25/97 A PreliminaryInvestigation was Completed Without Locating the Fuel

%?? Rods. .

m ust l

Q:2&. J-1

..e n

l '03/26/97 The Safeguards Coordinator Notified the CFFFPlant Manager and

) ^

Regulatory Affairs Manager;anda FormalInvestigation Team was Formed.

h 6

11 03/28/97- AnnualSNMPhysicalInventory- AllItems were Reconciled, Exceptfor uq"

^

, 2 04/06/97 the Two FuelRodsin Question. '

ry 04/05/97- The FormalInvestigation Team Identifieda Possible Scenario where the 04/09/97 Two FuelRods May Have Been Loadedinto One or Two " Replica"

't Assemblies Built and Shipped to the Temelin Flant; Additional

- Information was Gatheredto furtherSupport the Scenario.

e .

Fin W?: s fQl; -

, 1,.

• ~ ~ ~ ~ ~ ~ '

UENCE OFEVENTS(Cont'd) 4 10/9 7 The Temelin Plantin the Czech Republic was Informed ofthe Possible Scenario and Requested to Grant Permission for Two CFFF Representatives to Come to the Site to Confirm whether the Two FuelRods ,

1 g

m were in One or Both ofthe " Replica" Assemblies.

l

.A t

1. _l%O4i/5/97 Columbia Plant Personnel Arrive at the Temelin Site; NRC Informed that

~ "3 l the Two FuelRods May be Locatedin One or Both ofthe Temelin " Replica" Assemblies.

I r

i) 04/17/97 The Location ofthe First ofthe Two FuelRods in Question was Confirmed A in One ofthe " Replica" Assemblies; NRC Notified.  :

4 3pu;  !

04/18/97 The Second ofthe Two FuelRods in Question was Locatedin the Same

" Replica"Assemblyas the First; NRC Notified.

.. 05/12/97 Letters were Sent to AllApplicable Regulatory Agencies of Countries

$; Through Which the " Replica" Assemblies were Shipped, Notifying them of

& the Presence ofthe FuelRods in One " Replica" Assembly.

RL

]$ 05/23/97 _W CNFD PersonnelProvideda Status Update to Temelin Plant and CEZ

[f Ft Utility Representatives in the Czech Republic.

= $ ?!

i

TIONS TO RECOVER THE TWO FUEL DS A Plan Has Been DevelopedFor the Safe Return ofthe Two Fuel Rods From the Temelin Plant Site

• 1

?.7%{h

• The FuelRods willbe Re-Insertedinto the " Replica"Assemblyby

%f :

+ m Experiencedand Trained CNFD Personnel.

• The " Replica" Assembly willbe TransportedBack to CFFFin an i Approved Shipping Containerimmediately Following the Next l

m%

Shipment ofFuel Assemblies to the Temelin Plant.

45.' ,q

• AllAppropriate Licenses, Permits, Authorizations and Other Required Documentation WillBe Obtained Prior to Return of the Fuel Rods.

e 3

4 e

. , m m , r :- o -

ORTUNITIES FOR EARLIER' NTIF/CA TION ,

The Material Service A ttendant (MSA #2) Responsible for Reconciling items on the CFFF "7-Day Report" Failed to Perform this Function When the FuelRods First Appeared on the Report

~

on October 16,1996.

wpl,%

2 y l < ni From 10/16/96 to 3/20/97, the MSA Team Manager DidNot Require that the Location ofthe FuelRods be Determinedper i the "7-Day Report" Requirements or that, per CFFFProcedure, the Status ofthe FuelRods Be Reported to the Safeguards

}

x8 Coordinator as Potentially Missing. i ea

+ n The MSA's and Team Manager's Lack ofUnderstanding ofthe i Purpose and Use of the "7-Day Report,"and Failure to Follow l$

\Il g

ii CFFFProcedures, Prevented Proper Notification to the Safeguards Coordinator and Senior CFFFManagement and the R Prompt Resolution ofthe Location ofthe FuelRods per CFFF Procedure.

c g;,

1

?

a FIDENTIFICA TION ASPECTS CFFFPersonnel Did Self-Identify the Loss of Current Knowledge of the Location of the FuelRods in March 1997.

n i 4 4

. a . au Thereafter, CFFFSeniorManagementimmediatelyInstituted wwAT$+:

L Investigations that Located the FuelRods.

ha The FuelRods were Located, and the issues that Led to the NRC's Violations were Self-identified, Withoutan " Event"

}

y% Occurring.

+

't.;

..k 44 16

.,m. .

@1

-m vi

OTCAUSEINVESTIGA TION

• D CAUSAL FACTORS

-. .- . - .- -... .r a

Root Cause Team Established April 18,1997:

+

• Incident Treatedas a "Significant Condition Adverse to Quality"

-

• FormalRoot Cause Methodology (Tap Root Derivative) Employed with TrainedInvestigation Team tlT?Q1

• The Team was Tasked to Develop Scenario-Time-Line and

• A CausalFactors.

3 m Independent Management Oversight Team Established April  ;

3 l 4 18, 1997:  ;

• Appointedby CNFD GeneralManager

- Highly Experienced Team - Ledby_WBlairsville Specialty 7' Metals Plant Managerand Chairman ofthe Safeguards Rt - lJw Board vg

% - Membership Also Consisted of_WSafety Review Committee fli, Secretary, _WRegulatory Affairs Supervisory Engineer, and W 4 -

Assistant GeneralCounsel h ~

• The Team was Tasked to independently Review CFFF Investigatory Efforts and Ensure Appropriateness and

?$)

• } Comprehensiveness ofCorrective Actions.

OTCAUSEINVESTIGATION

• D CAUSAL FACTORS (Cont'd)

- ~.

Columbia Plant Corrective Action Committee (CAC) Approved the Root Cause Investigation Team's Report on April 30,1997and Grouped the CausalFactors anditems ofNote into 4 Major

% Management Oversight and ControlIssues for Corrective Action.

mm jm @2

,f _y.s

.m.

gY? The Identified Management Oversight and Controlissues

' Indicated the Need To:

.h 1

.k

• Ensure that There is an Appropriate Identification and Traceability T System for " Replica" Rods and Assemblies

• Instillin AllEmployees a High LevelofSensitivity to item Controland Accounting i

• Pro vide Impro ved Formal Communication Channels for Special or si UnusualRequirements

• Enhance Configuration ControlPractices, As Appropriate, for

. Production andInspection Equipment to Address Instances Where (G@

pl.

Such Equipment May Handle Both Uranium and Non-Uranium Bearing Materials in the CFFFMechanicalManufacturing Area.

i Y'

OTCAUSEINVESTIGA TION .

D CAUSAL FACTORS (Cont'd)

The CFFFCorrective Action Plan, Developedby the CAC, was Finalizedon May20,1997.

n i ?u The CNFD Independent Management Oversight Team Continued ytlf to Review the Corrective Action Plan and CAC Actions:

May 1,1997, Review with CNFD GeneralManager May 6,1997, Review with_WEnergy Systems Business Unit President The Overall Conclusion ofthe Management Oversight Team was that l CFFFManagement was Doing the Right Things:

%d - Investigation

* ~ - Root Cause Analysis

- Immediate Corrective Actions

- Corrective Action Plan Development.

9

id a The Corrective Actions Taken Included Specific Corrective Vh1 Actions in Response to the Four Identified Management fhi OversightandControlIssues. The Corrective Actions Also b

~

Address Each ofthe NRC's Apparent Violations.

9.

. , m m, r : s ~

MPREHENSIVEAND EFFECTIVE b RRECTIVEACTIONS w,m+-- . - -

t  %. p.

r. y ,,

MEDIA TE Corrective Actions

• The CFFFPlant Manager, Product Assurance Managerand Regulatory Affairs Managerissued a Letter on April 24,1997 y Stopping Shipments ofAll " Replica" Fuel Assemblies and Non-

@%NG Product FuelRods andRequiring Approvalfor Future 5" ^ Manufacture orMovement/ Transfer ofSuch items. (Addresses Violation 3,4,5)

Restrictions were to Remain in Place UntilEstablishment ofa Traceability Procedure to Ensure that No FuelRods Are Loadedinto

" Replica" Assemblies.

• A Letter willbe issuedin July,1997 Removing the Needfor Restrictions Basedon Lasting Corrective Actions Taken.

g n Assurance was Provided to CA C/ Product Assurance Manager that the Incident in Question was An isolated Occurrence and Cl that There was No Concern for Any Other Prior " Replica" or Non-Product Shipments, or for Normal Ongoing Shipments of h@ FuelRods orAssemblies. (Addresses Violation 3,4,5) p .a

~, *The Violation (s) Addressedby the Corrective Action are Indicatedin Parenthesis

. after the CA Description.

MPREHENS/VEAND EFFECTIVE RRECTIVEACTIONS(Cont'd)

. . .. ~

MEDIA TE Corrective Action

, n The CFFFPlant Manager Held a Mandatory AllManagement

. I W Meeting on May 1,1997to Emphasize the Importance ofitem 9tqh ControlandHave and to Ensure that AllManagers and Their 1 Employees UnderstoodApplicable RegulatoryRequirements.

w

~ (Addresses Violation 1,2,5)

}

The Plant Manager Administered A " Regulatory Training Quiz" Which

{ was Signed By Each Manager, Reviewed to Ensure Understanding na}

andSubmitted to the PlantManager.

i '

~

The Plant Manager Handed Out Section 5, " Safeguards, "of the CFFF Regulatory Training Manual, and Read Aloud the Text Under " General Safeguards"and " Item Control,"and InstructedEveryone to Read n the Balance of the Material on " Measurement Control, " " Uranium IN A ccountability"and "SNM In ventory. "

l$y

• The Plant Manager Distributed Copies ofa Letter Dated April 30, y 1997, Signed by Him and Entitled " Item Control ofNuclear Material, "

to Be DistributedandDiscussedby Each Manager With Each of Q) t His/HerEmployees.

i 1 O

me e$

I

, MPREHEl TIVEANDEFFECTIVE RRECTIVEACTIONS(Cont'd)

MEDIA TE Corrective Action The Plant Manager's April 30 Letter was Presented to Each gg Employee By His/Her Manager, EitherIndividually or Through

{ ggj"yj Group Meetings, to Ensure that AllEmployees Recognized that

• b " Item Controlis a Full-Time Responsibility - Every Hour ofEvery

' Day During the Entire Year. " (Addresses Violation 1,2,5)

8

• Each Manager Documented the Completion of this Action to the Plant b Manager.

@ili 7 m Immediate Retraining was ConductedforPersonnelInvolvedin the Incident; and Training Records and Documentation were Updated. (Addresses Violation 2,5)

% a Appropriate Management Action was Taken Regarding l$ PersonnelPerformanceIssues. (Addresses Violation 1,5)

IEb fh

,9 ,

> a j

$ nmmw r== n na

5 f

'MPREHENSIVEAND EFFECTIVE ,

'RRECTIVEACTIONS (Cont'd)

, ASTING Corrective Actions */**

n Actions Taken to Ensure that There Is An Appropriate

, ,a identification and Traceability System for " Replica" Rods: i vusawe jer:$3;1;j

1. c~'f 9. d A New Procedure was Established for Manufacture and g Mo vement/ Transfer of " Replica " Rods and Assemblies,

}

Which Ensures ProperIdentification ofSuch Rods and Assemblies During Processing and Requires a Radiation l, ,*) Survey of the " Replica" Rods or Assemblies by Regulatory

^} Engineering & Operations Prior to Shipping. (Addresses Violation 2,3,4,5)

)

• The Violation (s) Addressedby the Corrective Action is Indicatedin Parenthesis

'f to Afterthe CA Description.

(Iid -

' f?l **The Corrective Actions are Completed Unless Otherwise Noted.

t nmmw o- - e en

MPREHENSIVEAND EFFECTIVE

. RRECTIVEACTIONS(Cont'd) 1 STING Corrective Actions i

Q Actions Taken to Ensure that There Is An Appropriate pyr$5 en e Identification and Traceability System for " Replica" Rods D::M (Cont'd):

1 l

• A Regulatory Affairs Procedure was Modified to include '

j Requirements for Performing Radiation Surveys to Verify the x;) Absence ofSNMin Replica Rods or Assemblies. (Addresses ji Violation 2,3,4,5)

~

%

• A New Procedure was Established to Instruct Transportation and g Shipping Personnel that an Encapsulated Rod ofAny Length or Any

,y Type Must Have Either a QC Release or a Completely Signed off

$ SpecialRouting Before Shipment. (Addresses Violation 2,3,4,5) w$a W4

'- E s ,,

. -,,n-- n. . --

MPREHENSIVEAND EFFECTIVE .

RRECTIVEACTIONS (Cont'd) . ,

. . ." w * ' -W" e=w e- *

,, . . . . *1 t: *'Y - - -. 'A* ' d'-- . % .- M -

STING Corrective Actions a Actions Taken to Ensure that There is An Appropriate

Identification and Traceability System for " Replica" Rods IE@f}1 e

f il (Cont'd)

.. ' ,i .

y

• A Workplace Meeting Script was Written and Presented to All Rod ,

Inspectors to Indicate the Importance ofEnsuring that FuelRods Are

, Always SegregatedFrom Replica Rods. (Addresses Violation 2,3,5) epsy 3

Instructions Have Been Provided to the RodArea QC Team Manager  !

and Product Assurance Engineer to Ensure that Applicable Inspection Requirements, including SpecialInstructions, Are Q$ Specifiedon AllSpecialRoutings. (Addresses Violation 2,3,5)

.i D'; -

• A Plan is Being Developed to Provide an Improved Method to Ensure f A Timely FinalAccounting ofAllFuelRods When a Region ofFuelHas f*'

Been Completed. Action to be Completedby August 31,1997.

(Addre?ses Violation 1,5) m 4 -

MPREHENSIVEAND EFFECTIVE ,

RRECTIVEACTIONS (Cont'd)

ASTING Corrective Actions l p Actions Taken to Instilla High LevelofSensitivity to item Control:

w t x;4saft

.?o e w ' :J;]* MSA Training Records Have been Reviewedand Training StrengthenedAs Appropriate. (Addresses Violation 2,5)

- MSA #2Placedon a DocumentedPerformance improvement

? Program . Action to be Completed by July 31,1997. .

i - Training Guides Have been Reviewed, UpdatedandSignedoffby

.W ,

MSAs.

c

• ^ - A Letter was issued to AllManufacturing andInspection

' Managers to Review Employee Training Records and Update Training / Records As Needed;IsolatedInstances Required

s Updating andSignoff

ks - A Manufacturing Training Procedure was Revised to Ensure i,Q There is Proper Definition of Training Update Requirements.

kb Rj y:

i .-

, m m , a :- , , , , -

MPREHENSIVEAND EFFECTIVE RRECTIVEACTIONS(Cont'd) l STING Corrective Actions

. , ni Actions Taken to Instilla High LevelofSensitivity to item Control

i. g,n=A m, (Cont'd).

i L:

• Procedures were Reviewedand Strengthened to Ensure Item Control i Requirements Flow From Regulatory Affairs Through Manufacturing

? Operating Procedures.

- A Regulatory Affairs Procedure was Modified To Provide

1. ^;j Guidance To Ensure thatitem ControlRequirements Are ProperlyIncorporatedin Manufacturing Procedures. (Addresses

~

Violation 2,3,5)

- Area Manufacturing Procedures were Reviewed To incorporate p ProperInstructions Related to Using the "7-DayReport." Ten

• • Procedures were Revised, Reviewed, ApprovedandIssued.

(Addresses Violation 1,2,3,5) m 39, c

o 's..~

F

, , m m , ,- _ , -

t MPREHENSIVEAND EFFECTIVE RRECTIVEACTIONS(Cont'd)

I STING Corrective Actions n Actions Taken to Instilla High LevelofSensitivity to / tem Control 3

g&g;?g?

a (Cont'd):

g7 .y The CFFF "FundamentalNuclear Material Control"(FNMC) Plan was

, Revised And Submitted To the NRC for Acknowledgment To Clarify

}{ Ambiguous Language And to Add Two AdditionalCommitments for

} Timely Notification to the NRC Staff When a PotentialSafeguards u l;: IncidentIs UnderInvestigation. (Addresses Violation 1,5)

A Semi-AnnualAssessment ofEach Area's item Control

, Performance was Added As a Requirement of the Regulatory 8

if Inspection Process. (Addresses Violation 5)

I?bh is i

E_65 -

, ~>;

MPREHENSIVEAND EFFECTIVE -

1 RRECTIVEACTIONS (Cont'd) t STING Corrective Actions a Actions Taken To Provide FormalCommunication Channels for

\  ; 'L SpecialorUnusualRequirements-St@h -

we+ 1

,. 3

• Special Routing Instructions and Procedure References were  ;

i Clarified. (Addresses Violation 3,5) l 11 -

l

]

R A CFFF Team was Established to Ensure Applicable Requirements are Incorporatedinto Region Orders andFollowed Through to Certification. Action to be Completed By September 30,1997.

o *

(Addresses Violation 3,5)

& n Actions Taken To Enhance Configuration ControlPractices As Appropriate:

h y .

at mj .

• A CFFF Team was Establishedto Review Configuration Control

,  ? Practices in MechanicalProduction Areas. Action to be Completed by December 31,1997. (Addresses Violation 2,3,5)

/GA TIONFACTORS AND DISCRETIONARY NSIDERA TIONS '

iolation Severit Level /Penait AssessmentFactors i

qn Based on the NRC's Enforcement Policy (NUREG1600, as

? M Amended), the Collective Violations Shouldbe No Greater than

> yak

= r~? ! Severity LevelIll AND a CivilPenalty, ifAny, Shouldbe Mitigated: -

m -

! i

• W

_/CNFD/CFFFHas Not Had An Escalated Enforcement A ction During E the Past Two Years. i i

)

?

• W CNFD and CFFF Upper Management immediately Responded When

' ~

Notified By Appointing Both an Investigatory Team to Promptly Ascertain the Location ofthe FuelRods andIdentify Root Causes of the incident, andan Independent Management Oversight Team to

$9 Ensure Effective Investigations, Root Cause Determinations and

? Comprehensive Corrective Actions.

6 j,

• lmmediate and Lasting Comprehensive Corrective Actions Have fh" Been Taken to Prevent Recurrence of the Incident and the Occurrence offncidents that Could Have Similar Root Causes.

l

IGA TIONFACTORS AND DISCRETIONARY NSIDERA TIONS (Cont'd) e Use ofEnforcement Discretion is A ro riate T

v Based on the NRC'S Enforcement Policy, the NRC's Use of l 79 ggdee{n Enforcement Discretion Is Appropriate:

. re i  ?: . nA

~

= The Incident Received Attention at the Highest Levels of_W CNFD

? Management.

S i sh

• The Violations Involve No Safety Significance and Concern an L1 IsolatedIncident with Special Circumstances ofNon-Uranium  ;

Bearing " Replica" Assemblies.

y

• WHas Expended Significant Resources and Taken Comprehensive p3 and Effective Corrective Action to Prevent Recurrence of This and '

Mi Similarincidents. t pf

• The OverallSustained, Positive Performance ofActivities at CFFF ym -

ShouldBe Considered When Assessing the Violations.

a

. ha h..* 7/n /n 7 Ci.,n f on

P MARYAND CONCLUSIONS

_Wis in Basic Agreement With the NRC's Violations, Which Mirror the Findings ofits Own InternalInvestigations.

ps

=

mentn cem The Violations Presented No Safety Threat or Danger to the

W:L K Public, Workers at CFFFor the Temelin Plant, or to the Environment.

i

{ u The incident Has Been Treated Very Seriously by Wand CNFD Y]  ;

Management; andAppropriate Management Oversight Has Been Taken and WillContinue.

g n Relevant Circumstances Support Consideration By the NRC for f No CivilPenaltyAssessment:

h

• The Violations were Self-Identified Withoutan " Event" Occurring.

?!h -

• Comprehensive and Effective Correctiva Actions Are in Place to 10 n Prevent Recurrence and Similar Occurrences.

?g -

• ._W and CFFFHave a Long History ofSustained, Positive Performance

, andRegulatory Compliance.

t .. . - , m m , c:- , ~