PNO-IV-91-004A, on 910226,industrial Accident Occurred During Removal of Pipe Fittings from Halon Cylinder in Preparation for Weighing Bottle.Hospitalized Individual Developed Blood Pressure Problems & Test Continued to Determine Reason

PNO-IV-91-004A:on 910226,industrial Accident Occurred During Removal of Pipe Fittings from Halon Cylinder in Preparation for Weighing Bottle.Hospitalized Individual Developed Blood Pressure Problems & Test Continued to Determine Reason

ML20217B927
Person / Time
Site:	River Bend
Issue date:	03/01/1991
From:	Ray Azua NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To:
References
PNO-IV-91-004A, PNO-IV-91-4A, NUDOCS 9103120281
Download: ML20217B927 (2)

- , . . .- =. - .- -

. "Harch 1, 1991 y

, " PRELIMINARYJNOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE -- PN0-IV-91-04A

'.This preliminary notification constitutes EARLY notice of events of POSSIBLE l

> safety or public interest significana. The information is as initially received

, without verification or evaluation, and is. basically all that is known by the Hegion IV staff on this date.

FACILITY:' Gulf States Utilities Licensee Emergency Classification: l

. River Bend Station Notification of Unusual Event Docket No. 50-458 Alert j Site Area Emergency 1 General Emergency  !

X *Not Applicable i

SUBJECT:

INDUSTRIAL ACCIDENT DUE TO DAMAGED HALON CYLINDER - UPDATE j The-licensee's-invest 1gation of the Halon cylinder accident that occurred on February 26, 1991, at the River Bend Station (RBS), has yielded some preliminary '

determinations as to the cause of the accident. l The licensee .was performing a biannual surveillance of the Halon fire suppression system located in the services building. This surveillance was designed to  :

determine the Halon volume content-in each of the fire suppression system

. cylinders.

The licensee has detennined that the craftsmen removed piping fittings from the Halon cylinder in preparation for weighing the bottle. When the fittings were 'l removed, it caused the 2-inch valve assembly to onen and allowed the 200 pounds of liquid Halon.to escape. Two errors were believed to-have been made during i the removal.of the cylinder and its fittings. . First, when the Halon cylinder

was disconnected from the fire suppression system, the technicians failed, due to the initial physical orientation of the cylinder, to remove a pipe fitting

-from the discharge outlet of the valve located atop the Halon cylinder. As a result, the technicians were unable to install an anti-recoil plug on the valve discharge outlet, which would have prevented an as-rapid release of. cylinder q c.ontents. Secondly, it appears that a fitting was inappropriately removed due to inadequate instructions in a test procedure, resulting in the opening of the

. valve and the subsequent discharge of the cylinder contents. . ,

When the contents discharged, the 450-pound (fully-charged weight) cylinder became a missile, causing extensive damage to the area where the individuals were working. Gouges were made in the tile of a shower wall, ceramic tile was knocked toff a concrete floor leaving a 2-inch deep gouge in the concrete, tiles from a suspended ceiling were knocked off, and a hole (approximately 1-foot square) was made in a 6-inch cinder block wall'. ,

In response to this incident, the licensee has suspended the weighing of Hale

. bottles until all the root causes can be identified and appropriate corrective g actions taken.-

') The injured individual was not admitted to the hospital as earlier reported, but was held overnight for observation. The individual has developed blood pressure y w .f problems and tests continue to determine the reason. The individual was w subsequently admitted to the hosptial on February 28, 1991. ,

h

~No media interest has occurr>d nor has the licensee issued a press release. l T RIV:0:DRP R ); 9103120281 910301 h 1ns:cs @-I%1-0041PDR 1 4

7

.  ! Ma rch14, ?1991. 2- <

PRJ-IV,91-04A-

u .. ..

1Regioni!V received notif:ication'of' this- occurrenca by telephone froe the' ,

1icensee. ~ Region'IV hus informed EDO.i -NRR was notified by.theilicensee. 1

.This infonnation -has' been confirmed with a licensee' reprecentative.

1

n CONTACT: R. Azua, FTS 728-8291'-

DISTRIBUT:0N:'

OWFN NMBB NL' - MAIL:'DCS(Oria.IE34)  ;

Chmn. Carr. CA tR5T . ROU 'ES 00T(Transp..only) l cComm.; Rogers OGC -NRR -IRM' -dj -

g a (5520:4/ 1 3 /

Comm.'Curtiss' GPA SLITP OIG FAX:

Conin; Remick PA ' 0E TF0 Regions &HQ) j

. LACRS~ EDO PDR 1 j

L-St .NSAC j

F RRI- .. ,

~

EW4W NRC OPS Ctr .

)- %5 TAP Licensee (Reactor) i i je s-

!=

i' a 7 G

, 0

_=____ = _ . _ _ . , _