ML22278A339
| ML22278A339 | |
| Person / Time | |
|---|---|
| Site: | BWX Technologies |
| Issue date: | 09/22/2022 |
| From: | BWXT |
| To: | Masters A, Eric Michel NRC/RGN-II |
| References | |
| EA-21-035 | |
| Download: ML22278A339 (44) | |
Text
1 September 22, 2022 EA-21-035 Predecisional Enforcement Conference NRC Headquarters Rockville, Maryland - License Presentation
o Jim Bittner, Vice President and General Manager, NOG-L o
Rich Freudenberger, Environment Safety, Health & Safeguards Manager, NOG-L o
Daniel Ashworth, Licensing & Safety Analysis Manager, NOG-L o
Mark Elliott, Senior Director Safety & Security, BWXT Corporate o
Hope Cothran, Senior Counsel, BWXT Corporate o
Chris Dumond, Communications Manager, BWXT Corporate o
Lewis Csedrik, Counsel, Morgan Lewis & Bockius, LLP o
Paul Beers, Counsel, Glenn, Feldmann, Darby & Goodlatte NOG-L Attendees 2 - License Presentation
3 Jim Bittner Vice President and General Manager, NOG-L - License Presentation
4 NOG Organization - License Presentation
o Super Compactor (SC) Facility Overview o
Event Overview o
Investigation o
Corrective Actions o
Missed Opportunities o
Consequences o
Regulatory Perspective o
Enforcement Perspective o
Summary 5
Presentation Agenda - License Presentation
o In consideration of extensive investigation and corrective actions implemented by NOG-L as well as enforcement taken by OSHA, application of discretion is requested
Apparent Violations (a), (b), and (c) are similar in nature to the OSHA violations and appear to be an OSHA-covered, occupational issue; NRC Enforcement is not necessary Should NRC choose enforcement, these violations appear to be directly related to the same event; therefore, a single problem Discretion based on extensive corrective actions by NOG-L and enforcement taken by OSHA is requested; Severity Level III; no civil penalty
NOG-L is not in agreement with Apparent Violation (d)
Event was bounded by existing super compactor hydraulic system fire scenario Part 70 Performance Requirements were met Application of NOG-Ls ISA Methodology to the event scenario identifies it as out of scope Incomplete and inaccurate information citations are typically reserved for deliberate cases or impact to regulatory process
Apparent Violation (e) appears to be a non-escalated enforcement issue Missed opportunity associated with change Change did not result in increased radiological risk 6
Summary of NOG-L Message - License Presentation
7 Super Compactor Facility Overview Rich Freudenberger Department Manager, ESH&S - License Presentation
o 1,500 metric-ton press; reduces volume of drum and contents up to 90%
o Went into operation in 1991; used to compact Low Level Radioactive Dry Active Waste (DAW) generated at the site o
Compactor remained in operation until June 19, 2020 fire and fatality o
After that event, compactor was permanently disabled 8
Super Compactor Facility Overview - License Presentation
9 Super Compactor Facility Overview
- Random drum inspection occurred prior to batching drums and eventual transfer to compactor
- Operator worked in a Control Room and controlled operations via an automated control system
- Electrical sensors monitored movement of drums/equipment during processing; sensor status was displayed on control room computer monitor
- Drum was punctured prior to compaction to alleviate pressure
- Press mold lowered over drum; main press ram compacted drum producing compacted puck
- Puck was pushed off the base by puck unloader and placed into over pack by automated transfer system
- Over pack drum was sealed after all pucks had been added
- Over pack transferred out of SC Building by conveyor system Typical Compacted Drum (Puck) 55-Gallon LLRW Drum (Typical)
Super Compactor Press as viewed from Control Room - License Presentation
Super Compactor Facility Overview N
Waste Flow Fire Started at this Location - License Presentation
11 Event Overview - License Presentation
12 Fire in the Super Compactor (June 19, 2020) o Fire originated in Super Compactor Cell
Sprinklers and smoke detector activated
Fire Damage was limited to location of ignition source o
Operator was alone in the Cell at time of fire
Standard PPE for super compactor cell entry was worn
Interlock key was with employee o
Isopropyl Alcohol (IPA) was in Cell at time of fire
Last batch of drums compacted were Solvent Rags (2 drums)
Spray bottle containing IPA was found adjacent to operator o
Ignition source was a damaged low voltage DC electrical cable to a sensor
Sensor cable was energized at time of fire; on/off switch left in on position
Circuit arrangement with two (2) 15-Amp fuses in parallel on both the positive and negative legs
This permitted overcurrent condition which allowed a spark without the fuse blowing
Sensor cable was not one of the circuits de-energized as part of the conveyor interlock system
Investigation concluded that when contact was made between bare positive and negative wires, a sparks occurred capable of igniting the IPA vapors - Licensee Presentation
13 Interlock System and Sensor Power Supply Switch Interlock System o
Designed to shut-off all energy to mechanical parts in Cell (primarily conveyor system) o Did not de-energize sensor circuits o
Key to be removed to enter Cell (per procedure) o Key found with employee Interlock Key Sensor Power Supply On/Off Switch o
Turns power on/off to 28V DC circuit for sensors o
Use of switch not fully covered in training documents
Addressed turning power on before beginning operations
Did not specifically address turning power off prior to entering compactor cell o
Use of switch not covered in operating procedure Sensor Switch - License Presentation
14 Ignition Source Puck Unloader Position Sensor Electrical Cable o
Damaged cable found pulled from junction box connection on puck unloader o
Cover was off junction box and conductors were exposed; appeared to be pulled from point of connection to the electrical fitting o
Could not determine when damage occurred or how long existed o
No documented work orders requesting sensor/wire repair o
For reasons that could not be determined by investigation, employee entered super compactor cell after compaction o
Post-incident testing of circuit determined that interaction with, or agitation of, circuit wiring could cause sparking o
Sequence of ignition could not be determined; IPA vapor from spray bottle or liquid on the floor ignited - License Presentation
o Immediate
Fire extinguished
Area secured
8-hour Report to OSHA
Concurrent Report to NRC Operations Center
Investigation initiated
Super Compactor locked-out and tagged-out o
Short-Term
Eliminated use of spray bottles for alcohol application site wide
Conducted site wide review of IPA use and storage
Conducted chemical inventory and labeling review of the facility
Existing solvent rag drums conservatively re-classified as mixed waste until determination was made regarding the potential to contain free liquids 15 Actions - License Presentation
16 Investigation - License Presentation
o Investigation Efforts Included:
Root Cause Analysis (TapRoot) to identify causal factors and root causes
Investigation included Nuclear Work Model elements
Extent of Condition
Extent of Cause
Human Performance Review
Safety Culture Implications Review 17 Investigations and Reviews - License Presentation
o CF#1 - Operating procedure was not effective for requiring operator notifications of spills of alcohol in the Cell (Procedure was followed incorrectly) o CF#2 - Waste generating area operating procedure did not prevent wet rags from being packaged for eventual compaction (Procedure was followed incorrectly) o CF#3 - There were ignition sources in the Cell that do not appear to have been considered (Corrective Action needs improvement) o CF#4 - Use of switch that controls power to the sensors in Cell was not covered in the procedure (Inadequate procedure) o CF#5 - Sensor cable on the Puck Loader/Unloader showed signs of short circuiting at the connector due to exposed conductors contacting one another providing an ignition source (Inspection not required and no preventive maintenance for electrical equipment) 18 Causal Factors (CF) and Root Causes - License Presentation
19 Corrective Actions - License Presentation
o Plant
Permanently disabled the Super Compactor
Performed Hazard Hunts of manufacturing areas by area owners Hazard Communication Electrical Safety Machine Guarding Housekeeping
Reviewed the facility for high hazard equipment / operations for adequacy of preventive maintenance
Performing a comprehensive site wide assessment for hazards associated with use of alcohol and other flammables in presence of potential ignition sources including electrical hazards, due by October 26, 2022 20 Corrective Actions - License Presentation
o People
Developed a lessons learned presentation for operators regarding procedure related findings
Updated procedures and training documents for specific waste generating area operators and trained area operators
Performed retraining of waste generating area operators site wide regarding prohibited materials and content certification
Completed OSHA 30-hour training for Front Line Managers & Unit Managers with individual contributors as direct reports
Enhanced training for all employees and managers on the hazards of flammable liquids and vapors including the use of alcohol and other flammables in the presence of potential ignition sources including electrical hazards. Training is being conducted in parallel with annual general employee safety training.
21 Corrective Actions - License Presentation
o Processes
Conducted a review of the Hazard Communication program focused on chemical usage; including purchase, transfer, dispense, use and disposal
Reviewed a sampling of operations procedures for upset / abnormal conditions not addressed. Identified equipment manipulated without procedure guidance and cross walked between procedures, job aids and training materials.
Verified operating procedure format and content guidance documents included flow down of safety basis documents
Reviewed a sampling of safety basis documents for completeness and accuracy of supporting drawings, calculations and documents
Implemented a checklist for safety discipline review of changes that highlights hazards to be considered for all reviews 22 Corrective Actions - License Presentation
o Use and handling of flammable liquids o
PPE assessment - Fire retardant clothing o
Electrical safety compliance o
Assessment of satellite, remote, non-routine and lone-worker operations o
Safety Culture Assessments 23 Lessons Learned & Actions Applied to NOG Facilities Items Evaluated Across NOG Sites Administrative Controls Critical Steps in Procedures Documents Up to Date Preventive Maintenance Off Normal Conditions PPE Assessment Breaker/Fuse Coordination Conduct of Operations Procedure - License Presentation
24 Missed Opportunities - License Presentation
o 2004 - Cables and terminal blocks damaged in SC Cell due to over current condition
On/off switch and fuses added in parallel as opposed to being installed in series
Use of on/off switch mentioned in operator notes but not added to procedure or drawings o
2007 - Fire in waste drum during compaction
Suspended compaction of solvent rag drums until corrective actions could be implemented
Corrective actions were narrowly focused and relied on administrative controls
Minimizing use of IPA at the source
Inspection of drums
Spill notification requirements
Other possible ignition sources not considered
Equipment electrical classification discrepancy not recognized o
2012 - Change approved for compaction of solvent rag drums
Review of change predicated on Dry Active Waste (DAW) determination
Relied on corrective actions from 2007 event (changes to procedures); inadequate effectiveness review/verification
No overall restart review conducted (formal Conduct of Operations release procedure/process did not exist at that time) 25 Missed Opportunities - License Presentation
26 Consequences - License Presentation
o Site Daily Action Level air concentration is 80E-12uCi/ml o
The Super Compactor fixed air data, when shut down, was essentially the same as the results for the day of the incident o
Cell ventilation was filtered and monitored with no discernable increase during the incident o
Safety Analysis Report bounding fire case assumed a hydraulic fluid spill and fire o
The actual and potential radiological consequence from the radiological waste is independent of the flammable liquid involved 27 Radiological Consequences - Air Monitoring Fixed Air Levels (for Month before Incident)
Fixed Air Levels (Day of Incident)
Fixed Air Levels (for Month after Incident)
Drum Turn Table Avg. 3/1,000th of Action Level Max. 6/1,000th of Action Level 7/1,000th of Action Level Avg. 3/1,000th of Action Level Max. 6/1,000th of Action Level Drum Conveyor Avg. 2/1,000th of Action Level Max. 5/1,000th of Action Level 4/10,000th of Action Level Avg. 4/1,000th of Action Level Max. 8/1,000th of Action Level - License Presentation
o Smearable activity Action Limit for the controlled area was 5000 dpm (disintegrations per minute) o Area smears the month before, day of and the month after the incident are less than the clean area limit of 200 dpm o
The Super Compactor smear results before and after the incident were essentially the same o
Fire suppression water samples the day of the event were below release limits o
Actual/potential radiological consequences are significantly less than the bounding case analyzed in the Safety Analysis Report 28 Radiological Consequences - Smears / Samples Smear Levels (Month before Incident)
Smear Levels (Month after Incident)
Compactor Cell Avg (46 dpm )
Max. (110 dpm)
Avg (15 dpm )
Max. (42 dpm)
Drum Turn Table Avg. (10 dpm)
Max. (18 dpm)
Avg. (7 dpm)
Max. (8 dpm) - License Presentation
o Chemical Exposure event does not meet the threshold of Intermediate or High Consequence utilizing approved ISA Methodology o
AIHAs Emergency Response Planning Guideline & Workplace Environmental Exposure Levels does not provide acute toxicity values for Isopropyl Alcohol (IPA) o NIOSHs revised Immediately Dangerous to Life and Health (IDLH) value of 2,000 ppm is based strictly on safety considerations (i.e., being 10% of the lower flammable limit of 2%), not on exposure levels 29 Chemical Consequences Insignificant Chemical Exposure Consequences - License Presentation
30 Regulatory Perspective - License Presentation
o First and foremost, NOG-L recognizes and appreciates significance of event; one of our coworkers lost their life o
NRC - OSHA Memorandum of Understanding: Four (4) kinds of hazards that may be associated with NRC-licensed nuclear facilities:
a)
Radiation risk produced by radioactive materials; b)
Chemical risk produced by radioactive materials; c)
Plant conditions which affect the safety of radioactive materials and thus present an increased radiation risk to workers. For example, these might produce a fire or an explosion, and thereby cause a release of radioactive materials or an unsafe reactor condition; and, d)
Plant conditions which result in an occupational risk, but do not affect the safety of licensed radioactive materials. For example, there might be exposure to toxic nonradioactive materials and other industrial hazards in the workplace.
o Generally, NRC covers first three (3) hazards listed in paragraph 3 (a, b, and c), and OSHA covers the fourth hazard described in paragraph 3 (d) 31 Regulatory Perspective - NRC / OSHA (Occupational Safety and Health Administration) - License Presentation
o NRC Performance Requirements: 10 CFR 70.61 states that the risk of each credible event must be limited 32 Regulatory Perspective - NRC Performance Requirements High Consequence Event Intermediate Consequence Event An acute worker dose of 100 rem or greater An acute worker dose of 25 rem or greater An acute dose of 25 rem or greater to anyone outside of the controlled area An acute dose of 5 rem or greater to anyone outside of the controlled area An intake of 30 mg or greater of soluble uranium A 24-hour averaged release of rad material outside restricted area in concentrations exceeding 5000 times values in Part 20 An acute chemical exposure from licensed material or hazardous chemicals produced from licensed material (that could endanger life of worker)
An acute chemical exposure from licensed material or hazardous chemicals produced from licensed material (that could lead to irreversible/serious, long-lasting health effects to a worker) - License Presentation
o NOG-L Integrated Safety Analysis Methodology Implementing Procedure
[Quality Work Instruction 2.1.3, Attachment 7]
Addresses Hazardous Chemicals Produced from Licensed Materials
Philosophy reflects the NRC - OSHA Memorandum of Understanding o
The event appears to be primarily an OSHA-covered (occupational) event for which NOG-L received citations and a civil penalty through OSHA enforcement 33 Regulatory Perspective - NOG-L Integrated Safety Analysis Methodology Injury is not due to Hazardous Chemicals Produced from Licensed Materials (not regulated by NRC under 70.61)
An employee or member of the public is burned by a fire that is in the vicinity of or actually engulfs radioactive material; however, the fire cannot breach the clad material or threaten the safety of radioactive materials.
Example: Fire due to combustibles in a contaminated area where radioactive material, other than incidental contamination, is not directly involved in the fire. - License Presentation
34 Enforcement Perspective - License Presentation
o NOG-Ls understanding of the NRC Enforcement Manual, Part 1, Section 1.3.5, Documenting Violations, indicates that it may be appropriate to group violations as examples of a single problem under the following condition:
Violations should only be grouped if they are closely related such as having a cause and effect relationship or
[being] directly related to the same event (e.g., failure to perform testing that results in a piece of equipment being rendered inoperable, loss of material and failure to report the loss) 35 Grouping of Apparent Violations (a, b & c) - License Presentation
o Apparent Violation (a): Failure of the Fire Protection Program to control flammable liquids such that the spill and accumulation of isopropyl alcohol created a hazardous explosive [flammable] atmosphere that led to a flash fire and loss of life o
Apparent Violation (b): Failure to minimize free liquids in drums compacted for disposal such that the accumulation of excess quantities of this chemical created a hazardous explosive [flammable] atmosphere that led to a flash fire and loss of life o
Apparent Violation (c): Failure to control ignition sources such that an energized, bare (i.e., degraded) wire associated with the super compactor instrumentation circuit served as an uncontrolled ignition source for an ignitable vapor that contributed to a fire and loss of life 36 Grouping of Apparent Violations (a, b & c) - License Presentation
o Apparent Violations (a), (b), and (c) appear to be directly related to the same event; a fire in the super compactor cell causing loss of life o
Based on this understanding, NOG-L believes that Apparent Violations (a), (b), and (c) should be grouped into a single problem o
Apparent Violations (a), (b), and (c) are closely aligned with the enforcement action taken by OSHA for which NOG-L received citations and civil penalties o
As a result, it is further requested that NRC apply discretion to both the severity level and penalty applied, reclassifying the grouped violations to Severity Level III; without an additional civil penalty 37 Grouping of Apparent Violations (a, b & c) - License Presentation
o Apparent Violation (d), failure to maintain process safety information in the ISA that was complete and accurate in all material aspects such that the ISA did not identify the fire/explosion [flammability] hazards associated with the compaction of solvent rag drums o
NOG-L is not in agreement with this violation for the following reasons:
NRC Enforcement Manual indicates that escalated enforcement typically would only be considered if the incomplete/inaccurate information was submitted deliberately. [NRC Enforcement Manual Part II-1.5.3]
There is no indication of deliberate inclusion of incomplete/inaccurate information in the ISA There was no apparent impact to regulatory process
The regulations in 10 CFR 70.61 and 10 CFR 70.62 are specific to radiological and chemical risks produced by radioactive materials. Based on the specific event, there were low radiological and chemical exposure consequences produced by the radioactive materials The radiological safety consequences are discussed in Section 15.21.4.3 of the SAR; The low concentrations/quantities of radioactivity found in the LLRW processes minimize the likelihood and severity of a radiological accident.
Chemical exposure consequences did not meet ISA criteria of High or Intermediate Application of NOG-Ls ISA Methodology to the event scenario identifies it as out of scope 38 Apparent Violation (d); 10 CFR 70.9 Violation - License Presentation
Section 15.21.4.4 of the SAR discusses the process-related hazards associated with the super compactor (500-gallon hydraulic fluid reservoir) and fire protection system (automatic wet-pipe sprinkler)
Although the ISA did not specifically discuss a fire/flammability hazard associated with the compaction of solvent rag drums, a fire associated with the loss of hydraulic fluid containment is evaluated in the SAR and bounds the event The radiological component/consequence (i.e., from LLRW) is unchanged from the type of flammable material involved and is significantly less than the bounding case analyzed in the SAR o
==
Conclusion:==
There were low radiological and chemical exposure consequences produced by the radioactive materials
The specific accident sequence did not need to be analyzed; there were no high or intermediate consequences as defined by the ISA methodology, the process-related fire hazards included a bounding scenario and the Part 70 Performance Requirements were met
Application of NOG-Ls ISA Methodology to the event scenario identifies it as out of scope.
Therefore, the ISA is not incomplete and not inaccurate 39 Apparent Violation (d); 10 CFR 70.9 Violation - License Presentation
o Apparent Violation (e), failure of configuration control where a change was approved to compact waste drums containing alcohol that could present an increased radiological risk o
NOG-L acknowledges the review and approval of the 2012 change was a missed opportunity to prevent the event. Predicated on the determination that the waste was DAW (no free liquids) o The change did not result in an increased radiological risk o
The radiological consequence from LLRW during a fire in the super compactor is unchanged from the type of flammable material involved o
Processing of the change and the associated restart of the equipment in 2012 are not indicative of NOG-Ls current processes and programs o
Appears to be a non-escalated issue [NRC Inspection Manual 0616]; overall change in radiological risk was low; change did not present an increased radiological risk 40 Apparent Violation (e); Failure of Configuration Control - License Presentation
o OSHA citations and associated civil penalty o
Previous NRC Escalated Enforcement
No previous escalated enforcement actions within 2-years at the time of the event
In 2021, escalated enforcement was issued for a security issue unrelated to this matter o
NOG-L acknowledges violations were revealed by an event (i.e., fire)
The issue does not have a willful component NRC Office of Investigations concluded there was no wrongdoing OSHA citations were not characterized as willful
Detailed investigation was performed
Prompt and comprehensive corrective actions were taken
Lessons learned actions have been applied to BWXT Nuclear Operations Group facilities (5 locations) 41 Enforcement Process Considerations - License Presentation
42 Summary - License Presentation
o In consideration of extensive investigation and corrective actions implemented by NOG-L as well as enforcement taken by OSHA, application of discretion is requested
Apparent Violations (a), (b), and (c) are similar in nature to the OSHA citations and appear to be an OSHA-covered, occupational issue; NRC enforcement is not necessary.
Should NRC choose enforcement, these violations appear to be directly related to the same event; therefore, a single problem Discretion based on extensive investigation and corrective actions by NOG-L as well as enforcement taken by OSHA is requested; Severity Level III; no civil penalty
NOG-L is not in agreement with Apparent Violation (d)
Event was bounded by existing super compactor hydraulic system fire scenario Part 70 Performance Requirements were met Application of NOG-Ls ISA Methodology to the event scenario identifies it as out of scope Incomplete and inaccurate information citations typically reserved for deliberate cases or impact to regulatory process
Apparent Violation (e) appears to be a non-escalated issue Missed opportunity associated with change Change did not present an increased radiological risk 43 Summary - License Presentation
44 Jim Bittner Vice President and General Manager, NOG-L - License Presentation