ML20154B998

Package of Handwritten Statements Re Broken Crank Incident & LC Ellis 840419 Memo on Incore Thimble Ejection

ML20154B998
Person / Time
Site:	Wolf Creek
Issue date:	04/19/1984
From:	Albury D NRC
To:
Shared Package
ML20154B987	List: ML20154B983 ML20154B998
References
FOIA-85-706 NUDOCS 8603040531
Download: ML20154B998 (20)

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R. A. Sessoms 1760 CST 2-C

Subject:

SEQUOYAH NUCLEAR PLANT - UNIT 1 - INCORE THIMBLE EJECTION -

INVESTIGATION AND REVIEW OF EVENTS FOR INDUSTRIAL SAFETY IMPLICATIONS l =

Reference:

Your memorandum to me dated May 2,1984 (LO1840502 803) e As you requested in the referenced memorandum, an investigation committee 3 has , conducted an industrial safety evaluation of the subject incident.

- A r'eport of their findings is attached, a

7 4

L. C. Ellis Chariman, Investigation Comittee N

LCE:BLF N Attachment 3 cc (Attachment):

NUC pp ARMS _18i7n r%T7 c O H. N. Culver, 249A HBB-K James P. Darling,1750 CST 2-C

""3 Arthur E. Ives, 1350 CUBB-C C. C. Mason, NUC PR, Sequoyah Ji; Robinson, NUC PR, Sequoyah G. F. Stone, 215 MPB-M r

I

INCORE THIMBLE EJECTION - SEQUOYAH NUCLEAR PLANT, UNIT 1 An investi;ation committee composed of Lonnie C. Ellis, Jim Robinson, and Arthur E. Ives completed an in,dus_ u trial safety evahation.of the subject incident. The evaluation involved an inspection of the seal table area; review of procedures, sketches, and drawings; discussions with Westinghouse; and interviews with the majority of employees involved.

Those interviewed were J. Clif t. General Foreman; H. Gennage, Engineer; D. Albury, Steamfitter; and S. Harrison and M. Edwards, Health Physics 4 Technicians.

' We initially evaluated the incident based on its potential to have resulted in a fatality, hospitalization of five or more of the involved employees, and property damage of greater than $100,000. Although we would not waht to downplay the seriousness of this incident and the stress of the moment, there was in this case adequate prior warning of 04 bubbling and low-volume flow of relatively cool water to allow egress from the most remote point prior to total seal failure and subsequent C3 thimble tube ejection. There were three paths of egress, two of which were remote from each other, and the individuals involved were knowledgeable of them. The air lock was the most desirable and the one used.

RT The air lock had been out of service for periods of time during the day.

Welding under workplan 9606R2 was being done inside the air lock. This necessitated opening the outside door, thereby making the inner door

~~ inoperative. Had the incident occurred during this work, egress through the air lock would have been delayed or primary egress would have been pg through the submarine hatch.

Ps The incident in total will exceed $100,000 in property damage, cleanup, I3 and restoration. The majority of costs result from the radiological aspects of the incident. The Designated Agency Safety and Health j

c) Official and the Office manager were notified of the incident.

l l )

We do not believe this investigation was significantly hindered due to l

j the rt}toration of the area prior to our involvement. Only a visual j obser.ation of the ejected tube was not available to us and that was viewed on blown-up photos.

l l

l Sequence of Events Initial cleaning of thimble tubes was begun on March 28, 1984, and was reported complete on April 5,1984. The unit was in Mode 5. The thimble drive units were reinstalled and the incore probes were inserted to verify adequate cleaning. Several of the cleaned t abes failed to pass the thimble and others previously identified as clear were now identified i

as plugged.

1 .

1 S

i R

_=

Sequence of Events (continued) _

Subsequently, a maintenance request (attachment 1) was written or. 'i April 18, 1984, to dry brush the blocked thimble on the incore monitor a tubes. It was assigned to Field Services and was proceeding when the second shift reported on April 19, 1984. Applicable sections of a E

SMI-0-94-1 (attachment 2) were identified under work instructions for reference. [

D-12, the tube that failed, was not included in the maintenance request /

as a tube to be cleaned but was being used to measure the length of the '

. cleaning cable. -

3 A crew of six was assigned to brush the tubes. They were H. Gamage, y*

Engineer; D. Pascal, B. Simpson, and D. Albury Steamfitters; and -

l

5. Harrison and M. Edwards, Health Physics Technicians. The General -

o Foreman, J. Clif t, and the Steamfitter Foreman, C. Baker, were also 7 on the seal table platform observing the work and assisting as necessary, da

- Seven of the eight employees were arrayed on the seal table platform operating the brushing mechanism, while the eighth, Mr. Clift, was on j

' the platform above.

The reactor was in Mode 1 (approximately 30 oercent power) which places "

the pressure at 2250 psi and the temperature at 547 F.

i N. The specially designed brushing mechanism is composed of several feet of r heliflex cable fed through a stabilizing tube and forced through the a N thimble tube by a hand crank. Attachment 3 shows a cut-away detail of 7 f

the thimble tube connection. The hand crank is attached to the thimble ]

3 tube at point 1, with the brush entering the connection at that point. _

O The brush had entered at approximately one-half of the tube's 120-foot 2 O length and was meeting some slight increased resistance. Various levels of sound were heard by the involved employe2s and water began flowing 4 f rom the connection. The tube was not observed being ejected, nor was y steam o'> served at this time. The employees imediately left the platfore, opened and entered the air lock, and exited the area. Looking back ,

' through the air lock portholes they could see stear begin to build in -'

the room. Exit time from platform to safety in the air lock was no

-d greater than 20 seconds. Under the circumstances, the exit appeared 5 very orderly and there were no injuries.

The failure occurred at the reactor pressure boundary seal, point 82 (tttachment 3). This seal is obtained by a S/16-inch swagelok nut and ferrules crimped onto a smaller stainless steel heavy wall tube expanded to 5/16 inch. This union is protected from external tampering by a '=

plastic boot (point 3).

S

4 -

Conclusions _

Existing possibilities are The reason for the failure is not evident.

(1) the tube was not expanded sufficiently or to a sufficient depth (specifications require a minfmum of 1.5 inches), (2) the swagelon was i not tightened sufficiently (hand tight and 1.25 in the additiona was made, allowing the ferrule to relax, or (4) the partial crathThe flexing activity ferrule allowed the tube to be released.

brushing would have aggrevated any of the above conditions leading to the failure. Following this failure all fittings were checked and some SMI-0-94-1 states that this procedure is not to be used were tightened.

at power.

Since the unit was in Mode 1, this procedure was violated.

Recomendations All cleaning and brushing of these tubes should be done with the l1 reactor at Mode 5.

T O 2. If for some reason the brushing iteration is required past Mode 5, a thorough prejob safety analysis should be performed and the As a minimum, a mechanism should be procedure approved by PORC. installed to preclude tube ejection and l v -

of egress should be established.

I A rigidly mounted attachment should be fabricated on which the 3./ brushing mechanism and crank would mount which will eliminate any

~~

v .An alternative stress or flex on the thimble tube connection.

x pethod ctieaning which would mount independentTy of the thimble

.N tube _would be preferred.

U 4. All work on any system where there is no secondary pressure boundar should be evaluated on a case-by-case basis and adequate means O to riitigate an inadvertent pressure failure should be applied.

O 5. Ensure the constant availability of the primary egress route, te, the air lock. Consideration should be given to leaving the inner dent open (with the shift engineer's permission) or providing a person to man the door.

6. Ensure that all emergency notification systems are in co operation.

event.

i 7.

Reinstall the plastic boots or install other reeans around all

! reactor pressure boundary seal unions to prevent tampering.

B.

Comend the eight employees for their coolness ;nder pressure and their ability to reason through egress options under the stressful l -

situation.

I LCE:BLF 5/14/84 i

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October 15, 1985 nucear owareness networc 1347% massachusetts . laurence, kansas 66044 .(913)749-1640 Director PREEDOW OF INf 0HMAION Office of Administration ACT REQ 0EST as n , 2 5 FREEDOM OF INFORMATION ACT REQUEST oG- /N/-M To Knom It May concern:

Pursuant to the Freedom of Information Act, U.S.C. 522, as amended, the Nuclear Awareness Network requests the following documents regarding the Wolf Creek Nuclear Oenerating Plant.

Please consider " documents" to include reports, studies, test results, correspondence, memoranda, meeting notes, meeting minutes, working papers, graphs, charts, diagrams, notes and summaries of conversations and interviews, computer records, and any other forms of written comnunication, including inter-nal NRC staff memorands. The documents are specifically re-quested from, but not limited to, the following offices of the NRC: Office of Analysis and Evaluation of Operational '

Data (AEOD); Office of Nuc1 car Reactor Research (NRR); Office of Nuclear Regulatory Research (Research); Office of Inspection and Enforcenent (I&E); Office of Investigations (OI); Generic .

Issues Branch of the Division of Safety Technology, and the Operating Reactors Branches of the Division of Licensing.

In your response, please identify which documents correspond to which requests below.

Pursuant to this request, please provide al] docunents prepared or utilized by, in the possession of, or routed through the NRC related to the Wolf Creek Nuclear Generatirg Plant:

1.) Any and all information relating to the "Sequoyah Incident" which would have occurred prior to August 20, 1985--

probably during 1984. This incident occurred during a maintainence procedure which involved Chuck Mason and 3 othdr workers who may have been put in jeopardy. It was purported'to have been investigated by the Nuclear Safety Review Staff (NSRS) which is a part of TVA, and reports were made to a Mr. Willis at TVA. Included in this re-quest are any and all documents submitted by TVA, NSRS, and/cr Mr. Willis on this sub ject.

2.) Any and all information surrounding an incident on or about August 4, 1985 involving a release, or potential release, of radiation at Wolf Creek into the cooling lake and/or atmosphere.

Aids w a. ' u ..-

If any of the material covered by this request has been des-troyed and/or removed, please provide all surrounding docu-mentation, including but not limited to a description of the action (s) taken, relevant date(s), and justification (s) for the actions.

For any documents or portions that you deny due to a specific FOIA exemption, please 1:rovide an index itemizing and describing the documents or portions of documents withheld. The index should provide a detailed justification of your grounds for claiming each exemption, explaining why each exemption is rele-vant to the document or portion of the document withheld. This index is required under Vauchn v. Rosen (I), 484 F.2d 820 (D.C. Cir. 1973), cert. denied, 415 U.S. 977 (1974).

b'e look forward to your response to this request within ten days.

Sincerely, I /

'AP7 ) Le< w c

Stevi Stephens S