ML20207L783

Insp Repts 50-259/86-38,50-260/86-38 & 50-296/86-38 on 861015-17.Violations Noted:Failure to Adequately Control SNM & to Comply W/Transportation & Disposal Requirements for SNM

ML20207L783
Person / Time
Site:	Browns Ferry
Issue date:	12/04/1986
From:	Hosey C, Weddington R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
To:
Shared Package
ML20207L734	List: ML20207L731 ML20207L759 ML20207L783
References
50-259-86-38, 50-260-86-38, 50-296-86-38, EA-86-194, NUDOCS 8701120346
Download: ML20207L783 (11)

See also: IR 05000259/1986038

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UNITED STATES

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NUCLEAR' REGULATORY COMMISSION

y n REGION il

y j 101 MARIETTA STREET, N.W.

• g ATLANTA, GEORGIA 30323

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JAN 0 219[87

Report Nos.: 50-259/86-38, 50-260/86k38, and 50-296/86-38

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Licensee: Tennessee Valley Authority

6N38 A Lookout Place

1101 Market Street

Chattanooga, TN 37402-2801

. Docket Nos.: 50-259, 50-260 and 50-296 ~ License Nos.: DPR-33,'DPR-52,

and DPR-68

Facility Name: Browns Ferry 1, 2, and 3

. Inspection Conducted: October 15-17, 1986

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Inspector: I /

R. E. Weddingtop v Date Signed

Approved by: I M /A/% (t

C. M. Hosey, Section Chief Date Signed

Division of Radiatior' Safety and Safeguards

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SUMMARY

Scope: This was a special, unannounced onsite inspection in response to the

reported loss of five fission counters containing special nuclear material.

Results: Six violations characterized in the aggregate as a single significant

issue were identified for failure to adequately control special nuclear material

and to comply with transportation and disposal requirements for special nuclear

material. .

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REPORT DETAILS l

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1. Persons Contacted

Licensee Employees

• H. P. Pomrehn, Site Director

• R. L. Lewis, Plant Manager

• D. C. Mims, Technical Services Superintendent

• A. W. Sorrell, Site Radiological Control Supervisor

• J. E. Swindell, Unit Superintendent

• R. D. Schulz, Compliance Manager

• T. D. Cosby, Unit Superintendent

• R. McKeon, Unit Superintendent

• E. A. Grimm, Plant Staff

• J. M. Corey, Radiological Control Supervisor

• D. C. Smith, Chemistry Supervisor

• D. A. Pullen, Office of Nuclear Power Site Representative

• J. Savage, Licensing

• R. R. Davis, Licensing

• S. Jones, Plant Operations Review Staff

• P. Whitt, Radwaste Engineer

• D. S.- Hixson, Radwaste Supervisor

• R. Burns, Instrumentation and Control .

• R. H. Albright, Radiological Control Supervisor

• J. Shaw, Shift Technical Advisor Supervisor

M. Totten, General Foreman

C. Hill, Boilermaker Foreman

M. Miller, Shift Engineer

S. Hinkle, Special Nuclear Material Custodian's Aide

J. Lewis, Special Nuclear Material Custodian

Other licensee employees contacted included technicians, security. force

members, and office personnel.

Nuclear Regulatory Commission

• G. L. Paulk, Senior rsesident Inspector

• C. A. Patterson, Resident Inspector

• C. Brooks, Resident Inspector

• Attended exit interview

2. Exit Interview

The inspection scope and findings were summarized on October 17, 1986, with

those persons indicated in Paragraph 1 above. Six violations characterized

in the aggregate as a single significant issue for failure to adequately

control special nuclear material and to comply with transportation and

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disposal requirements for special nuclear material (Paragraph 3) were

discussed in detail. The licensee acknowledged the inspection findings and

stated that they believed there was no deficiency in their reporting of the

apparent loss of special nuclear material in that they had felt that the

material was onsite and would be located during their search. The licensee

did not identify as proprietary any of the materials provided to or reviewed

by the inspector during this inspection.

3. Apparent Loss of Special Nuclear Material-(93700)

a. Background

This special inspection was performed to determine the circumstances

surrounding the apparent loss of five fission counters containing

special nuclear material (SNM). The fission counters, also known as

" dunking chambers" or fuel loading chambers (FLCs), consisted of

approximately 3-inch diameter and 12-inch long cylindrical detectors

internally coated with two grams of uranium enriched in the isotope

U-235 to 92.58 percent. The fission counter body had attached a hose

to supply N, gas to the detector and a conduit containing

instrumentation leads. Four of the fission counters were attached to

approximately 14-feet long control rod guide blades. The fission

counters were used to provide a source count rate during refuelings

when the installed source range monitors (SRMs) would approach the

lower limit of their detection capability. The licensee's fuel

assembly reloading pattern was changed in 1984 so that source count

rate would always be on the SRM scale, making further use of the

fission counters unnecessary during refuelings.

Through review of records a'nd discussions with licensee

representatives, the inspector determined the history of the fission

counters while they were at the licensee's facility. The five fission

counters were received on April 1,1976, from General Electric and

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entered into the licensee's SNM accountability system. The fission

counters were loaned to Cooper Nuclear Station on September 21, 1976.

On September 10, 1977, the fission counters were returned to the

licensee's facility. The fission counters were stored on the refueling

floor until they were moved for use to Unit 1 on July 27, 1981. On

February 25, 1982, they were moved to Unit 3, on January 25, 1983, they

were moved to Unit 2 and on November 1,1983, they were moved to

Unit 1. Following their last use, the four fission counters attached

to guide blades were stored in a wooden box approximately 4-feet square

and 14-feet long. The fifth fission counter, in an approximately

18-inch square box, was stored with the larger box. The boxes were

stored on the refueling floor or in one of the unit's equipment pits

when they were drained.

On July 25, 1986, the licensee attempted to conduct a physical

inventory of the fission counters. The fission counters could not be

located on the initial search of the refueling floor. Subsequent

expanded searches were also unsuccessful. On October 10, 1986, the

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licensee appointed an internal investigations officer to coordinate the

search for the fission counters, to collect historical data related to

their whereabouts and to obtain written-statements from personnel. On

October 14, 1986, Region II was informed that the fission counters were

potentially lost.

b. Licensee Investigation

The licensee's investigation into the. potential loss of the fission

counters was still officially in progress at the time of the

inspection, but was essentially complete except for drafting a report. .

The inspector discussed the circumstances surrounding the. event with

the investigations officer and other licensee representatives, reviewed

the documents relating to the fission counters that had been assembled

and conducted interviews with selected licensee employees.

The licensee had concluded that the five fission counters had been

inadvertently shipped on March 4,1985, to the low level radioactive

waste disposal site near Richland, Washington in a package containing

radioactive waste. The inspector reviewed-the documents, statements,

and other basis for the licensee's conclusion. ,

On July 23, 1984, the P' ant Manager issued a memorandum discussing the

state of housekeeping on the refueling floor and directing that the .

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area be cleaned such that protective clothing would not be required for

access to any area on the refueling floor. For approximately the next

seven months, two shifts of workers were. assigned to decontaminate and

clear the refueling floor of unneeded material. A waste disposal

station was established in the drained Unit 3 equipment pit. The pit

was covered and a portable band saw was used to section material, which

was then loaded into metal waste boxes that had been lowered into the

equipment pit.  ;

The inspector reviewed a series of Special Work Permits (SWPs) that had

been prepared for the disposal work during the period January 22-28,

1985. Licensee representatives stated that no other SWPs could be i

found for the cleanup work which referred to the fission counters

(dunking chambers). SWP No. 01-2-24216, dated January 22,1985, was

titled " Cut Unit 3 Equipment Pit (Dunking Chambers) Equipment" and gave

the radiation and contamination levels on the fission counters. SWP

No. 01-2-24216, dated January 23, 1985, was titled " Cut Up Dunking

Chambers Unit 3 Equipment Pit." SWP No. 01-2-24226, dated January 27,

1985, was titled " Package Metal and Hoses in Rad Waste Container" and

gave radiological data on the dunking chambers. SWP No. 01-2-24228,

dated January 28, 1985, was titled " Refuel Floor Unit 3 Equipment Pit

Load LSA Box" and gave radiological data on the dunking chambers. A

special instruction on the SWP also stated that the chambers were to be

loaded with slings.

The inspector reviewed the written statements from personnel who had

been involved in this work. No one recalled who directed that the

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fission counters be prepared for disposal or specifically recalled

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pl_ acing the fission detectors in the waste box. Several workers did

recall portions of activities, such as cutting up the guide blades and

placing them in the waste box and also placing in the waste box other

smaller boxes (possibly containing the fifth fission counter).

The licensee was able to trace the movement of the waste box after it

was removed from the equipment pit from radiation survey records and

log book entries. The waste box remained on the refueling floor for a

period of two to four weeks. At the latter part of February 1985, the

box was moved to the equipment airlock on the 565' elevation and then

to the radioactive waste. staging area located on the southside of the

plant.

Radiation surveys that had been performed on the refueling floor of the

waste box indicated that the box had radiation levels of

.150 millirem / hour at contact and 50 millirem / hour at three feet. The

licensee reviewed records of radioactive waste shipments that had been

made during the end of February and March 1985. All waste shipments

were sent to the disposal site near Richland, Washington during this

period.- Shipment No. 2886 on March 4,1985, consisted of ten metal

waste boxes, of which one had radiation levels recorded on the shipping

papers comparable to those measured on- the box while it was sti,ll on

the refueling floor. No unique identification number was assigned to

waste boxes until they were in the shipping staging area so that

tracking by radiation levels measured on the box was the only means of

determining in what shipment the fission counters were likely included.

Based on the records and statements reviewed and on discussions with

licensee representatives, the inspector also concluded that the five

fission counters were likely included in the radioactive waste box that

was shipped on March 4, 1985.

c. Regulatory Implications

(1) Special Nuclear Material Control and Accounting

(a) Procedures

10 CFR 70.51(c) requires that each licensee who is authorized

to possess at any one time special nuclear material in a

quantity exceeding one effective kilogram of special nuclear

material shall establish, maintain, and follow written

material control and accounting procedures which are

sufficient to enable the licensee to account for the special

nuclear material in his possession under license.

The inspector reviewed NRC License Nos. DPR-33, 52 and 68 for

the Browns Ferry facility. Paragraph 2.B(2) of the license

authorized receipt, possession and use at any time up to

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600 kilograms of contained uranium-235 in connection with

operation of the facility.

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The inspector reviewed licensee procedure TI-14, Special

Nuclear Material Control, Revision 4, dated September 25,

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1986, which detailed the licensee's special nuclear material

control and accounting procedures.

. Paragraph 5.0 of TI-14 required that except as noted, all

inventories will be documented by use of an "SNM Inventory

Form" (Attachment C).

The inspector. reviewed the inventory records for.SNM other

than fuel. The fission counter inventories were annotated on

the " History Form" for the item, which was a summary form

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showing receipt and transfers of the items. However, there

was no SNM Inventory Form for the fission counters and

licensee representatives stated.that_none had been maintained

for the items since they had been received by the licensee on

April 1, 1976. - Failure to document the fission ' counter

inventories on an SNM Inventory Form as required by licensee

procedure was identified as an apparent violation of'

10 CFR 70.51(c) (50-259/260/296/86-38-01).

Paragraph 2.4 of TI-14 defined SNM storage areas as the new

fuel storage vault, spent fuel storage pool, reactor and

warehouse.

Based on record reviews, the inspector determined that the

five fission counters were stored on the Unit 3 refueling

floor and in the Unit 3 equipment pit during the period

November 1, 1983, to January 22, 1985. These areas were not

designated as authorized SNM storage areas. Storage of SNM

outside of areas designated for such material by licensee

procedure was identified as an additional example of an

apparent violation of 10 CFR 70.51(c) (50-269, 260,

296/86-38-01).

The inspector determined that it was the licensee's practice

to complete an NRC Form 741 for nonfuel SNM, such as the

fission counters, movements from one unit location to another

if the item was going to be used in the new location. If the

movement was for storage, no NRC Fonn 741 was required. For

this reason, no authorization paperwork was required when the

fission counters were moved to the Unit 3 equipment pit and

apparently placed in the waste disposal box. The history

forms for the items indicated they were assigned to a given

unit, but in some cases were actually located within another

unit. The licensee's procedure did not address prior

authorizations and paperwork required to move nonfuel SNM,

although it was the licensee's practice to use NRC Form 741

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to document some movements. Failure of the licensee to

establish adequate procedural controls for nonfuel SNM

movem:nts was identified as an additional example of an

apparent violation of 10 CFR 70.51(c) (50-259, 260,

296/86-38-01).

(b) Records of Transfer

10 CFR 70.54(a) requires that each licensee who transfers

speciai nuclear material shall follow the requirements set

forth in the 10 CFR 74.15(a).

10 CFR 74.15(a) requires each licensee who transfers special

nuclear material shall complete and distribute a Nuclear

Material Transaction Report on DOE /NRC Form 741. This should

be done in accordance with the printed instructions for

completing the form whenever the licensee transfers a

quantity of special nuclear material of 1 gram or more of

contained uranium-235.

The five fission counters that were apparently transferred to

the disposal site each contained two grams of urania.n

enriched in the isotope U-235 (92.58 percent). Since the

licensee did not know at the time that the fission counters

were in the waste box, no NRC Form 741 was prepared for the

transfer. Failure of the licensee to prepare a transfer

report was identified as an apparent violation of

10CFR70.54(a)(50-259,260,296/86-38-01).

(c) Report of Loss

10 CFR 70.52(a) requires that each licensee shall report

immediately any loss, other than normal operating loss, of

special nuclear material.

The five fission counters could not initially be found on

July 25, 1986, during the annual physical inventory.

Licensee management was notified that the fission counters

were not where they were thought to have been on

approximately August 5, 1986. Searches for the items

continued through early October 1986, when an internal

investigations officer was appointed.

The inspector reviewed licensee reportable event

determination (LRED) 86-0-617 dated October 12, 1986. The

LRED was a form used by the licensee to document the

evaluation of an event's reportability. The determination

documented on the form was that the potential loss was not

reportable pursuant to 10 CFR Part 73 and licensee procedures

because the items would not pose a substantial hazard to

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persons in unrestricted areas and the loss did not occur

during transportation.

On the morning of October 14, 1986, Region II was informed of

the problem and the licensee investigation that was being

conducted. The inspector informed the licensee that the

apparent loss was reportable pursuant to 10 CFR 70.52(a).

The licensee then officially reported the apparent loss later

that day.

Licensee representatives stated that the apparent loss of the

fission counters was not reported sooner because they had

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wanted to explore all possible leads in their search for tne

items and everyone believed that the items had to be

somewhere onsite. The inspector stated that he understood

the licensee's desire to make a thorough search, however, a

12-week reporti; g delay from when the items could not

initially be. located was excessive in light of the immediate

reporting requirement. Failure of the 1icensee to

immediately report the loss of the fission counters was

identified as an apparent violation of 10 CFR 70.52(a)

(50-259,260,296/86-38-01).

(d) Transfer of Special Nuclear Material

10 CFR 70.42(c) requires that before transferring special

nuclear material to a licensee of the Commission or an

Agreement State, the licensee transferring the material shall

verify that the transferee's license authorizes receipt of

the type, form and quantity of special nuclear material to be

transferred.

Since the licensee did not know the fission counters were in

the waste disposal box shipped on March 4, 1985, no

verification was made that the licensee was authorized to

receive the material. The licensee did not have a copy of ,

the disposal site's NRC Special Nuclear Material License

onsite, but one was located at the Corporate Office and

verified that the fission counters did not contain SNM of a

type, form or quantity contrary to the disposal site's

license possession limits. Failure of the licensee to verify

that the disposal site was authorized to receive the type, i

form and quantity of SNM transferred prior to the shipment

was identified as an apparent violation of 10 CFR 70.42(c)

(50-259,260,296/86-38-01).

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(2) Transportation of Special Nuclear Material and 10 CFR Part 61

(a) Shipping Papers

10 CFR 71.5(a) requires that each licensee who transports

licensed material outside of the confines of its plant or

other place of use, shall comply with applicable requirements

of the regulations appropriate to the mode of transport of

the Department of Transportation (DOT) in 49 CFR Parts 170

through 189.

49 CFR 172.203(d) requires that the description for a

shipment of radioactive material on a shipping paper must

include the name of each radionuclide . in the radioactive

material, .the activity contained in each package and the

words " Fissile Exempt" if the package is exempt pursuant to

49 CFR 173.453,

49 CFR 173.453(a) states that fissile material packaging

requirements do not apply to a package containing not more

than 15 grams of fissile radionuclides.

The inspector reviewed the shipping papers for the March 4,

1985 Shipment (Number 2886) to the disposal site near

Richland, Washington which apparently included the fission

counters.

The inspector determined that the names of the radionuclides

within the radioactive material listed on the shipping paper

failed to include the uranium-235 that was present. The

activity listed as being contained within the package did not

include the activity of the uranium-235 within the fission

counters. The fission counters contained less than 15 grams

of fissile radionuclides (i.e., 10 grams U-235) and therefore

met the fissile material packaging exemption, however, the

shipping paper was not annotated " Fissile Exempt." These

deficiencies in the shipping papers for Shipment Number 2886

were identified as an apparent violation of 10 CFR 71.5(a)

(50-259,260,296/86-38-01).

(b) 10 CFR Part 61

10 CFR 20.201(b) requires that each licensee shall make or

cause to be made such surveys as may be necessary for the

licensee to comply with the regulations in 10 CFR Part 20.

10 CFR 20.311(d)(1) requires that radioactive wastes be

classified according to 10 CFR Part 61.55.

During review of statements from workers involved in loading

of the material in the equipment pit into waste boxes, the

inspector noted that the waste box which apparently contained

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the fission counters had reportedly been shielded internally

with scrap sheet lead that was also in the equipment pit

awaiting disposal. The inspector also noted that the same

dose to curie conversion factor had been used to estimate the

activity within all ten boxes which comprised Shipment Number

2886, although the differences in shipping weights for each

box given on the shipping papers indicated that some of the

boxes may have been shielded Linterna11y. Licensee

radioactive waste personnel stated that, at the time the

shipment was made in 1985, there was no control in place to

make the person performing the activity calculation aware

that a box was shielded. Failure to take this into account -

would result in an underestimatation of the activity within

the package.

The activity within -the box which apparently contained the

fission counters (Package Number FB-85-2638) was listed on

the shipping papers as being. 0.047 curies. Licensee

radioactive waste personnel recalculated the package activity

based on radiation survey data that was available for

components that had been placed in the package and determined

that the package had contained approximately 1.9 curies of

activity. The licensee also determined, and the inspector

verified, that this change in activity would not have

resulted in a change in the waste classification, calculated

pursuant to 10 CFR Fr.rt 61, for the package, although the

potential for improper classification did exist since nuclide

conce.ntrations were calculated based on the product of the

percent abundance of each nuclide and the total activity

within the package. Failure of the licensee.to perform an

adequate evaluation of the activity within the package was

identified as an apparent violation of 10 CFR 20.201(b)

(50-259,260,296/86-38-01).

4. Enforcement Conference

An Enforcement Conference was held on November 4, 1986, at the licensee's-

Browns Ferry facility to discuss the circumstances surrounding the loss of

the five fission counters and the licensee's corrective actions for the

special nuclear material control and accounting and transportation

violations identified during the inspection. T.he following persons were in

attendance:

a. Tennessee Valley Authority

H. P. Pomrehn, Site Director

R. L. Lewis, Plant Manager

C. G. Robertson, Director, Nuclear Services

R. L. Gridley, Director, Nuclear Safety and Licensing

J. Robertson, Chief, Nuclear Fuel Engineering

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M. J. May, Manager, Site Licensing

D. C. Mims, Technical Services Superintendent

J. L. Lewis, Special Nuclear Material Custodian

S. Hinkle, Special Nuclear Material Custodian's Aide

R. D. Shulz, Compliance Manager

J. Shaw, STA Supervisor

D. A. Pullen, Office of Nuclear Power Site Representative

C. W. Beasley, Information Officer

T. A. Ippoleto, Licensing Consultant

b. Nuclear Regulatory Commission

J. P. Stohr, Director, Division of Radiation Safety and Safeguards

D. M. Collins, Chief, Emergency Preparedness and Radiological

Protection Branch

K. P. Barr, Chief, TVA Projects Branch

R. E. Weddington, Senior Radiation Specialist

G. L. Paulk, Senior Resident Inspector

J. W. York, Senior Resident. Inspector (Bellefonte)

C. A. Patterson, Resident Inspector

C. R. Brooks, Resident Inspector

A. H. Johnson, Project Engineer

Licensee personnel acknowledged that there had been an apparent breakdown in

their control of nonfuel special nuclear material. Corractive actions at

the site and corporate level to preclude recurrence were presented. These

actions included a hundred percent records and physical accounting of all

nonfuel special nuclear material that had been received at the facility,

procedural and program changes to enhance identification and control of

special nuclear material, training of personnel, increased controls on the

packing of radioactive waste containers and actions directed to improving

the effectiveness of the radwaste group. Licensee personnel stated, in

regard to reporting the apparent loss of the material, that they had not

intentionally delayed reporting the loss since the deficiencies in their

accountability program had made it difficult for them to ascertain that the

items were in fact not present.

NRC personnel asked questions related to the identification of root causes

and generic implications of the event. The need for improvements in the

transportation area was also emphasized. Licensee personnel stated that

their formal internal and corporate investigation reports would be sent

shortly to Region II and that the reports would contain a detailed

discussion of the corrective actions they had taken or planned,

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