ML20207L783
| 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: |
| 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
Text
.
F
w.
b
+[>2Effo
NUCLEAR' REGULATORY COMMISSION
UNITED STATES
'
o,d
y
REGION il
n
y
j
101 MARIETTA STREET, N.W.
g
ATLANTA, GEORGIA 30323
%.,,..
JAN 0 219[87
'
Report Nos.: 50-259/86-38, 50-260/86k38, and 50-296/86-38
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
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
'
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.
.
$
~
'
.
s
'
? & 1120346 % 0
'
G
ADock o
59
,
-,. , , - - . , - .
.
2
REPORT DETAILS
l
-
-
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
.
3
l
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
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
,
'
.
,
4
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
.
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
'
.
5
fission counters be prepared for disposal or specifically recalled
-
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
_
h
+
,
6
600 kilograms of contained uranium-235 in connection with
operation of the facility.
The inspector reviewed licensee procedure TI-14, Special
'
' Nuclear Material Control, Revision 4, dated September 25,
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
-
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
2
--
.
.
.
7
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
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
)
.,
8
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
-
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).
i
!-
!
i
!
.-
.
. - -
. - . -
_
- -
. . - .
- - -
__
,
< . -
9
(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 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
- . . - - - -
--
. - . . . - - . . - - - -
- - . . . - , - - . , - .
.
10
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
.
11
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,
i
.
d