ML20236K337
| ML20236K337 | |
| Person / Time | |
|---|---|
| Site: | Vermont Yankee, 05000000 |
| Issue date: | 05/13/1986 |
| From: | Murley T NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | Heltemes C NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD) |
| Shared Package | |
| ML20236K265 | List:
|
| References | |
| FOIA-87-377 NUDOCS 8708070083 | |
| Download: ML20236K337 (10) | |
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NUCLEAR REGULATORY COMMISSION
l REGION I 0,
a 631 PARK AVENUE
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Kisc or Pauss:A. PENNSYLVANIA 19406 MAY 131986 MEMORANDUM FOR:
Clemens J. Heltemes, Jr., Director, Of fice of the Analysis and Evaluation of Operational Data FROM:
Thomas E. Murley, Regional Administrator, Region I
SUBJECT:
DRAFT INPUT TO A0 REPORT TO CONGRESS FOR FIRST QUARTER CY 1986 As requested in yc;r April 7,1936 memorandum, the Region I staff has prepared input for the subject A0 report.
Attached are A0 writeups for the following:
1.
Inoperable Standby Liquid Control System Vermont Yankee, February 8, 1986 (Advance copy provided to P. Bobe of your staff on April 29,1986).
2.
Management Deficiencies at an irradiator Facility Radiation Technology, Inc., February 26, 1986 3.
Therapeutic Medical Misadministration Washington Hospital Center, February 6, 1986.
(Advance copy of items 2 and 3 provided to P. Bobe of your staff on May 5, 1986)
Also attached is material updating A0 85-10 (Pittsburgh Testing Laboratory),
Region I believes that the A0 inolving Radiation Technology, Inc. should be handled as a new A0 and not as an update to A0 77-10.
Should you have any questions or require further information, please contact Kenneth Murphy a,t FTS 488-1210.
hi Thomas E. Murl.
m Regional Administrator l
Attachments: As Stated 1
l CC:
l H. R. Denton, Director, NRR J. G. Davis, Director, NMSS R. B. Minogue, Director, RES l
N J. M. Taylor, Director, IE l
N G. H. Cunningham, Executive Legal Director N J. J. Fouchard, Director, PA sG. W. Kerr, Director, SP l
Regional Administrators N
9708070083 8708d4 PDR FOIA GDRDONB7-377 PDR L
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VERMONT YANKEE DRAFT 4/25/86 REPORT TO CONGRESS ON ABNORMAL OCCURRENCES JANUARY - MARCH 1986 NUCLEAR POWER PLANTS The NRC is reviewing events repcrted st nuclear power plants licensed to operate during the first cuarter of 1986.
As of the date of this report, the NRC had determined that the following were abnormal occurrences.
86-XX Inoperable Standby Liquid Control System The following information pertaining to this event is also being reported con-currently in the Federal Register.
Appendix A (see general criterion #2) of this report notes that a major degradation of safety-related equipment car; be considered an abnormal occurrence.
Date and Place - Durir.g a surveillance test at Vermont Yankee in February, 1986, the Standby Liquid Control (SLC) system was found to be inoperable l
l when explosive squib valves failed to actuate.
Although the SLC system was not required to be operable at the time of the test (since the plant l
was shutdown and defueled to replace the recirculation system piping), the system was not functioral as required by the technical specifications during the plant operating cycle that started in July, 1934 cod ended in September, 1985.
Vermont Yankee is a boiling water reactor (SWR) designed by the General Electric (GE) Company, and is operated at licensed power levels up to 1598 MWt by the Vermont Yankee Nuclear Power Corporation (VYNPC).
The plant is located in Southeastern Vermont in the Town of Vernon.
Nature and Probable Consequences l
The SLC requires manual initiation and explosive firing of two parallel redundant squib valves to inject borated water into the reactor vessel in the event that soluble boron is required as a backup to the control rod system for reactivity control.
During surveillance tests on February 8 and 11, 1986 with the plant shutdown and cefueled both valves failed to fire when called for by the system initiation switch.
As a result, during plant operating cycle #11, which ran from July 1984 until September 1985, the SLC system was not available ss a backup to the control rod system because the squib discharge valves would not have opened upon demand.
The control rods and the reactor protection system were oper-able during the entire period when the SLC system was not functional.
Additionally, the Recirculation Pump irip (RPT) and Alternate Rod Insertion (ARI) systems were operable dur the last operating cycle.
In the event 1
that an anticipated transient ha. occurred concurrent with the failure of the control-rod scram function (an ATWS event), the RPT system could have
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been used to mitigate the event by reducing reactor power, and the ARI system l
could have been used to provide for slow rod insertion.
If slow rod inser-tion using the ARI system had also failed, then no additional reactivity control system would have been available to mitigate the consequences of the event.
Cause or Causes i
Permanently installed plant wiring is connected to the explosive squib valves to provide firing circuits and firing circuit continuity monitoring.
The squib valve is actuated by shearing a cap on the valve inlet fitting, which opens a flow path through the valve.
The cap is sheared off by a trigger assembly that is actuated by either of two explosive charges in the l
primer subassembly.
The primer charges for a squib valve are ignited by I
the firing circuit by concurrently applying 120 VAC to bridgewires embedded in the charges.
When the SLC system is in the standby mode, the electrical continuity of the squib valve firing circuit is monitored and indicators are lit on the control room panel when a firing path for each valve exists.
During surveillance tests on February 8 and 11,1986, both the A and B valves failed to fire when the control switch was placed in the System 1 I
and System 2 positions, respectively.
It was notable that the continuity monitoring circuits for both valves indicated the system was "reacy to fire" However, the firing circuits could not work as wired.
Investiga-tion of the firing circuits found that the primer chamoers within each squib valve were mis-wired by having both 120 VAC high side leads wired to one ignition bridgewire, and both neutral leads wired to the other bridge-wire.
Both squib valves were last tested satisfactorily during a July 11, 1984 surveillance.
The replacement squib valve explosive primers, installed following the July 1994 test and presumed to be electrically the same as the primers successfully fired, were electrically different due to a changed connector pin to bricgewire configuration.
The primer wiring change was a manufacturing error unknown to the vendor, Conax Corporation of Buffalo, New York, that had not been detected by the licensee during receipt inspec-tion or preservice testing of the parts prior to installation in the SLC I
system.
The design of the continuity monitoring circuit was not capable of detecting the problem.
The principle cause for the squib valve failure and the loss of he SLC i
function was the incorrect wiring in the primer chamb r supplied by the manufacturer in 1983 and initially installed in July, 1984 A total of 6 defective primer chambers were identified either installed or in stores at l
the Vermont Yankee site.
Following notification of the problem at Vernont i
Yankee, the vendor identified 51 other possible defective primer chambers that had been supplied to other facilities.
Actions regarding this item are discussed further below.
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A secondary cause for the event was the f ailure by Vermont Yankee to de-tect the manufacturing defect prior to using the parts in the plant.
The error was identified by the 'Jermont Yankee staf f in February 1956 while testing the installed valves at the end of the operating cycle.
If a test had been conducted for a representative sample of the chambers installed in the SLC in 1984, the loss of the SLC function could have been prevented.
Although a squib valve from the vendor's same manufacturing lot was " bench" tested in the plant maintenance shop prior to installation, the " bench" test was deficient in that it only verified the adequacy of the explosive material, but did not test the electrical wiring configuration.
NRC inspection also found irregularity'es in the plant wiring in that the as-found firing circuit wiring differed from the design drtwings.
The difference occurred following a design change to the firing circuits in 1977 when difficulties encountered during tne installation resulted in a needed field modification of the firing circuit. The adequacy of the mo-dified circuit was demonstrated by the successful completion of the annual surveillance tests from 1977 to 1984 with primer chambers of the type sup-plied in 1977.
However, the field modification did not go through the normal review process and therefore was not reflected in a change to the as-built drawing of the firing circuit.
Since the fie?d modification I
would have been approved in 1977 if submitted, the primary cause for the SLC system failure remains the primer manufacturing errcr and the failure of Vermont Yankee to detect the error.
Actions Taken to Prevent Recurrence Licensee - Licensee actions to prevent recurrence of the event were in progress as of the date of this report anc were under review by the NRC Region I staff.
All defe:+ive primer chambers were separated from good ones and plans were in progress to return the defective ones to the vendor.
Changes were made to the procecures used to test the primer chambers to correct the, deficiencies in the " bench" test, and to provide for an in-si-tu test of a representative primer chamber from the vendor's same manufac-turad lot prior to use of new chambers in the SLC system.
The surveillance testing of the SLC system will be repeated using the updated procedures prior to declaring the SLC system operable and installing fuel in the reat-tor.
The licensee plans to evaluate the feasibility and cost benefit of making the continuity monitoring circuit foolproof.
Plant design drawings will be updated to reflect the as-built conditions.
Plant startup from the recirculation pipe replacement outage is scheduled for June 1986.
NRC - The NRC Region I staff is reviewing the Vermont Yankee corrective actions and will verify actions are completed to restore the SLC system to an operable status per the technical specifications prior to subse-quent plant operations.
Following notification of the SLC test failure, the NRC worked with the Vermont Yankee and Conax staffs to determine whether the problem applied to ether operating plants.
The vendor identified 6 plants aside from Ver-mont Yankee that could possibly have defective parts.
The NRC staff issued
4 IE Information Notice 86-13 on February 21, 1986 to all EWR facilities to describe the problems at Vermont Yankee and to recommend actions be taken l
at the other facilities to check the SLC firing circuits and the primer l
Chambers supplied by Conax.
The information notice also identified the l
plants that had potentially suspect primer chambers.
Part numbers and serial numbers of the suspect chambers were also previded.
Based on sug-gestions from the Vermont Yankee staff, the NRC staf f is planning to issue a supplement to Information Notice 86-13 that will clarify the cause of the problem end emphasize to power plant utilities the importance of ade-l quately testing vendor supplied parts prior to use at the facility, i
I Vendor - The Conax Corporation submitted a report to the NRC on March 5, i
1986 per the requirements of 10 CFR Part 21 to describe the nature and the probable cause of the manufacturing error.
The error occurred during a temporary change in the manufacturing location for the parts and was caused by a combination of assembly and inspection by inexperienced personnel, the lack o# connector pin identifications on the connector, and by incorrect assembly operation sheets for the primers.
Conax icentified a corrective action plan in the Part 21 report that, when completed, should p~revent recurrence of the manufacturing error.
The vendor also reported that, based on telephone contacts with other users of the potentially defective l
parts as of February 28,1986, no other faulty units had been located.
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ABNORMAL OCCURRENCE DESCRIPTION l
86 - XY Breakdown of Manecement Control Date and Place:
NRC inspections in 1984 and 1986 at the Rockaway, New Jersey facility of Radiation Technology, Inc. identified a number of instances of bypassing safety interlock systems.
These indicate a significant breakdown in the licensee's management control program.
This f acility is located in Morris County, New Jersey.
Nature and Probable Consequences:
Radiation Technology, Inc., has been licensed to operate a large irradiator near Rockaway, New Jersey since November 1970.
The licensee's irradiator uses sealed cobalt-60 sources to produce high intensity gamma ray fields for the sterilization of medical equipment and supplies and for various other industrial l
and scientific applications.
In addition, the licensee has lona sought FDA l
approval to irradiate food products for routine consumption. fMartin A. Weltj j
Ph.D., is President, ChairmanoftheBoardofDirectorsandtheRadiationSafetyl Officer for RTI.
RTI also owns and operates irradiators through wholly owned subsidiaries in North Carolina and Arkansas, both Agreement States.
Another wholly owned sub-sidiary, South Jersey which was licensed by Region I on March 14, 1986.
RTI has been the subject of several escalated enforcement actions in the past; the most noteworthy being in 1977 (Abnormal Occurrence 77-10), when a plant worker at the Rockaway facility was able to walk into the irradiation room while the cobalt-60 was exposea because safety interlocks on the personnel access door, designed tg prevent such entry, had been made inoperable.
The employee J
received a radiation cose of 150-300 rem, far in excess of regulatory limits.
The license was temporarily suspended following this incident until the licensee took necessary corrective actions.
The events giving rise to the most recent suspension Order first came to light during a routine'NRC inspection in September 1934 The inspecter discovered that the licensee had been operating the irradiator since April 1984 with an inoper-able safety interlock on one of the two conveycr caenings useo to transfer pro-duct into the irradiation room.
On September 26, 1984, Region I issued a Confir-matory Action letter that documented the licensee's commitment to operate the facility only if all safety interlocks were operable and to cease operations if any safety interlock failed to function as required.
Review of relevant documentation by the inspector indicated that this bypassing of interlocks was implemented by the operators under the supervision of the Operations Manager.
In November 1985, the interlock was replaced with a new design without required NRC approval.
A0 REPORT VY - 0005.0.0 11/29/80 1
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During n recent inspection on February 26, 1986, the staff determined that the licensee had been operating the facility for several days prior to the inspection in spite of the malfunction of a radiation monitor which actuates the lock that i
assures that the personnel door to the irradiation room cannot be opened while i
the sources are exposed.
Rather than fix the monitor prior to continued opera-I tion, as is required by the license, the licensee chose to operate the irradia-I ter and, when necessary, opened the door by improperly tripping the door lock when the cobalt-60 appeared to have returned to its shielded position.
Follow-ing this discovery, the staff requested that the licensee cease all operations until the monitor was repaired, conducted daily inspections te assure the facility
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was being operated safely and that all interlocks were functioning and prepared j
an Order Suspending the License which was issued on March 3, 1986.
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Subsequently, the licensee requested lifting of the suspension by letters to l
the NRC dated March 4 and 5, 1986.
After the Region 1 staff met with the li-censee on March 6, a more complete submission was provided by the licensee on March 10.
This latter submission proposed interim plant operations under the surveillance of an independent Third Party, reporting airectly to a aember of the RT1 Board of Directors, who, alcag with the licensee, would be responsible for assuring that the facility would be operated safely and in compliance with all NRC requirements.
Further, an independent Fourth Party would monitor the activities of the Third Party on a weekly basis.
Both parties would provide uncensored reports directly to the NRC.
Following consideration of this propos-al and agreement of the licensee to additional items, the staff concluded that temporary resumption of facility operations under these conditions would not endanger the health and safety of the public.
Accordingly, a Conditional Re-scinding of the Order Suspending License was issued on March 13, 1986.
The I
licensee agreed to the terms of this Order in a letter dated March 13, 1986.
Cause or Causes:
Serious breakdown in the licensee's management controls.
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A0 REPORT VY - 0006.0.0 11/29/80
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Actions Taken to Prevent Recurrence i
N3C:
1.
The enforcement actions described above.
2.
The NRC is continuing to inspect the performance of this licensee at frequent intervals.
3.
Further enforcement action is pending.
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l Licensee.
The licensee is in compliance with the Order.
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r A0 REPORY VY - 0006.1.0 11/29/80
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ABNORMAL OCCURRENCE DESCRIPTION
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86-YY Therapeutic Misadministration Date and Place:
On February 7,1986, a patient at Washington Hospital Center, Washington, D.C., received a radiation therapy dose of 150 rads which was intended for another patient.
Nature and Probable Consequences: On February 6, 1986, an ettending surgeon on the Renal Transplant Unit ordered radiation therapy as follows for one of his patients:
150 rads per day to be repeated every other day for a total of 600 rads.
The treatment was intended to forstall rejection of the kidney implanted on the previous day.
The unit clerk, in entering the order for the i
treatment into the computer for transmission to the Radiation Therapy Department for scheduling purposes, ordered the treatment for the wrong patient through careless use of the computer light pen.
The wrong patient, who was also a kidney transplant recipient, was brought to the radiation therapy department on the morning of February 7.
A radiation therapy physician checked her chart, noted that there was no order in the
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chart for radiation therapy, but, contrary to hospital policy, directed the technologist to administer the treatment, since the computer schedule showed this patient's name.
The mistake was discovered that af ternoon and the l
correct patient was subsequently treated.
i The consequence of this incident was that the patient received 150 rads, contrary to the wishes of her physician.
Her physician stated, however, that l
if in the future she showed rejection of the kidney that had just been implanted, he would prescribe a similar course of radiation therapy.
Other physicians who perform renal implants routinely prescribe radiation therapy without waiting for evidence of rejection.
Cause or Causes:
Failure on the part of a radiation therapy chysician to follow proper procedure and not investigate why a patient presented for therapy did not have an order written in her chart.
l Actions Taken to Prevent Recurrence The NRC issued a Confirmatory Action Letter, documenting the licensee's commitment to have a consultation between the referring physician and the i
radiation therapist before any therapy.
This was hospital policy for all l
radiation therapy except for renal transplants.
The incident is being reviewed by an NRC medical consultant and enforcement action is being considered.
l A0 REPORT VY - 0007.0.0 11/29/80 l
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9 A0 85-10 (Update) Breakdown in Manacement Controls l
Pittsburgh Testing Laboratory l
Pittsburgh Testing Laboratory was fined 515,000 in Federal District Court on February 19, 1986 as a result of its guilty plea to violation of 18 USC 1001, l
Subsequently, the NRC, on April ',1986, issued a Netice of Violation and Proposed Imposition of Civil Penalties in the amount of 558,000.
This enforce-ment action was taken because of the deliberate violations of NRC requirements, the f falsification of records by site management, and the lack of candor, demon-strated by both site and corporate management in their dealings with the NRC, i
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I A0 REPORT VY - 0007.1.0 11/29/80 l
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