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 Start dateReporting criterionTitleEvent descriptionSystemLER
ENS 4193319 August 2005 19:30:00ResponseNrc Bulletin 91-01 Violation of Criticality Spacing Requirements

Criticality spacing configuration requirements for Integrated Fuel Burnable Absorber (IFBA) rod caskets were violated in the IFBA loading dock (Dock 9). IFBA rod caskets are used for transport of IFBA rods from the IFBA loading dock to the Quality Control (QC) Inspection Area. Criticality spacing requirements for the caskets are posted on the lid of each container. The requirements state that loaded caskets are required to remain in the same horizontal array with 12-inch spacing between all other containers not in the same array. As such, stacking of loaded caskets is prohibited. Contrary to this requirement, Westinghouse operations personnel identified several caskets loaded with IFBA rods that were stacked in the IFBA loading dock (Dock 9). It is believed that this spacing condition was present for less than 24 hours, although this has not yet been confirmed. Notification is being made based on the loss of spacing of the caskets in conjunction with the failure to limit the potential pathway for moderator introduction into the caskets (see discussion below for more detail). Double Contingency Protection The criticality safety analysis considers criticality not credible for normal and credible process upset conditions. However, the criticality safety analysis (ISA-12) also establishes that criticality is possible if large quantities of rods were stacked and interstitial moderation was provided and retained among the stacked fuel rods. Introduction of interstitial moderation is limited by the casket covers and through limitation of available sources. While no liquid moderator was present in any of the caskets, the potential pathway for moderator introduction was not addressed by either the criticality safety posting (deficiency in the criticality safety analysis) or operating procedures. In addition (as discussed under the Reason for Notification), the caskets were improperly spaced in a stacked configuration. It was determined that the criticality safety analysis is deficient and that less than two unlikely, independent, and concurrent changes in process conditions would be required before a criticality accident would be possible. A criticality is judged to be credible through the introduction of moderation and the incorrect configuration of the caskets. In accordance with Westinghouse Operating License (SNM-1107), paragraph 3.7.3 (b.3), this event satisfies the criteria for a 4-hour notification. Summary of Activity:

 IFBA casket loading operations were discontinued.
 Operations Management reviewed the procedural requirements prohibiting stacking of caskets with all of the operations personnel.
 The program to train and re-certify all Operations personnel is continuing, per schedule.  
 The program to assess and reconstitute the plant's criticality safety basis is continuing, per schedule.   
"Conclusions:
 Problem was self identified by Westinghouse Operations personnel.  As stated previously it is believed that the improper spacing configuration was present for less than 24 hours. 
 Less than double contingency protection remained.
 No liquid moderator was present in any of the caskets.
 At no time was the health or safety to any employee or member of the public in jeopardy.  No exposure to hazardous material was involved.
 The Incident Review Committee (IRC) determined that this is a safety significant incident in accordance with governing procedures.
 A causal analysis will be performed.
 The plant programs for training and recertification of operations personnel and for assessment and reconstitution of the plant's criticality safety    basis are appropriate corrective actions for this type of event and are continuing according to plan.

There is no NRC Resident Inspector at the site. The loading operations are estimated to be discontinued for 3 to 7 days.

ENS 4172320 May 2005 22:40:00Response
Part 70 App A (B)(5)
Deviation from Integrated Safety Analysis, and a 24 Hour Notification - Bulletin 91-01 Criticality Control

Facility Westinghouse Electric Company, Commercial Fuel Fabrication Facility, Columbia, SC, low enriched PWR fuel fabricator for commercial light water reactors.

Time and Date of Event May 20, 2005, 1840 hours. Reason for Notification During a routine filter change-out in a HVAC recirculation filter housing, maintenance mechanics detected an excessive amount of material buildup on the filters and contacted the ventilation engineer. Human performance training at the plant has engendered a heightened awareness for process upsets or unusual conditions in all plant personnel. The ventilation engineer examined the filter housing beneath the filter array and discovered a minor build up of powder in the corners of the housing. This caused him to contact the Nuclear Criticality Safety function. The ventilation engineer and the NCS engineer had samples pulled from the powder and filters to confirm the absence of uranium. The system was believed to serve hoods where entrainment of uranium was not credible, i.e. hoods that contained only sintered pellets, not powder in any form. The samples from the filters returned results in a range from 3.5 to 50 weight percent uranium (average 19 weight percent). This notification (Deviation from Integrated Safety Analysis) is made in accordance with Appendix A ((b)(5)(i)) to Part 70 - Reportable Safety Events. Events to be reported to the NRC Operations Center, (b) within 24 hours of discovery, (5) An occurrence of an event or process deviation that was considered in the Integrated Safety Analysis and : (i) Was dismissed due to its likelihood. As Found Condition The samples from the filters returned results in a range from 3.5 to 50 weight percent uranium (average of all samples for filters was 19 weight percent). An approximate mass of material mass held up in the filters is 119 kg. Based on the average weight percent uranium, the mass of uranium held up in the filters was 22.6 kg, which is less than a critical mass for spherical fully reflected UO2 and water system. The system was already shut down for filter replacement. Summary of Activity The entire functional area that the system serves was shut down immediately. A team of process experts, system experts, NCS specialists, maintenance personnel, and management was immediately formed to determine the source of the uranium in the system. Conclusions At no time was the health or safety to any employee or member of the public in jeopardy. No exposure to hazardous material was involved. The Incident Review Committee (IRC) has determined that this is a safety significant incident in accordance with governing procedures. A causal analysis will be performed.

HVAC
ENS 4141817 February 2005 17:00:00Response
Part 70 App A (B)(1)
24 Hour 91-01 Response Bulletin and Part 70 App a Unanalyzed Condition
ENS 413724 February 2005 14:00:00Response24-Hour Notification-Bulletin 91-01 Criticality Control

The following information was obtained from the licensee via email : Facility: Westinghouse Electric Company, Commercial Fuel Fabrication Facility, Columbia SC, low enriched ((DELETED)) PWR fuel fabricator for commercial light water reactors. License: SNM-1107.

Time and Date of Event: February 4, 2005, 0900 hours:

Reason for Notification: Double contingency protection for non-favorable geometry (NFG) bulk containers is based on preventing moderation from entering the bulk powder blending room and by then preventing the moderator from entering the bulk containers. Prevention of moderation from entering the bulk powder room is assured by controls such as a double roof, restrictions on firefighting combined with limits on combustible materials, limits on moderators for maintenance and cleaning, and rigorous control over powder moisture to ensure that no carts enter the bulk room that have polypaks with moisture above 0.3 wt%. Prevention of moderator from entering the bulk container is assured by controls such as procedure requirements to ensure visual inspection of all powder before it is dumped into a bulk container and the polypak dump hood interlock system. In order to dump a polypak into a bulk container, the operator must scan the polypak's unique barcode and place the polypak into the polypak dump hood mechanism. After the barcode is scanned, the interlock function checks the moisture data associated with the polypak to ensure it is <0.3 wt%. If the moisture results are not <0.3 wt%, the dump hood locks up, preventing further dumping of powder until the discrepancy is resolved. During routine dumping operations, an infrared (s)ensor became misaligned in the polypak dump hood in bulk powder blending room. This resulted in a failure of the polypak dump hood interlock to finish its 'cycle' for that pack. It was expected that this sort of problem would be promptly self revealing, i.e. that the scanning of the next pack would result in an error indicating that the previous pack had not been 'consumed.' While the errors were generated, they were not readily apparent, except to an attentive operator. The barcode scanner sounded the same, the visual cues were subtle, and the dump (hood) interlock did not lock up. The operator was able to scan additional paks and dump them. The moisture database would not have been consulted for any of these paks. In accordance with Westinghouse Operating License (SNM-1107), paragraph 3.7.3 (c.5b), this event satisfies the criteria for a 24-hour notification, specifically, 'Any nuclear criticality safety incident, in an analyzed system, for which less than previously documented double contingency protection remains (multi-parameter control or single-parameter control) and less than a safe mass is involved.' and 10CFR70, specifically Appendix A.b.2 'Loss or degradation of items relied on for safety that results in failure to meet performance requirements of 10CFR70.61.'

As Found Condition: An operator found the problem after dumping the first polypak of a blend.

Summary of Activity: The affected equipment has been shut down. New programming and other improvements are being developed.

Conclusions: There was less than a critical mass of SNM involved. At no time was the health or safety to any employee or member of the public in jeopardy. No exposure to hazardous material was involved. The Incident Review Committee (IRC) has determined that this is a safety significant incident in accordance with governing procedures. A causal analysis will be performed. The licensee will be notifying NRC Region II of this incident.

ENS 4098524 August 2004 14:05:00Response24 Hour 91-01 Response Bulletin

An incorrect valve line-up caused a batch from the solvent extraction system to be pumped to the uranyl nitrate bulk storage tank without having the necessary sample results for grams U-235 per liter, percent free acid, and pH. It was determined that approximately 38 gallons of uranyl nitrate at 4.6 grams U-235, 8 percent free acid, and a pH of 1 was pumped to the bulk storage tank. These parameters meet the requirements for an authorized pumpout. The bulk storage tank contained approximately 1600 gallons of uranyl nitrate at approximately 1.4 grams U-235 per liter, 11.6 percent free acid, and a pH of 1. Double contingency protection for the bulk storage tank is based on concentration control. Concentration control is based upon maintaining uranyl nitrate that is pumped to the tanks at less than 5 grams U-235/liter. The pH is maintained at a value of less than 2 to ensure that the uranyl nitrate stays in solution. The percent free acid is maintained at greater than 4 percent to ensure that the uranyl nitrate stays in solution and depresses the freezing temperature of the solution to prevent concentration by freezing. It has been determined that less than previously documented double contingency protection remained for the system and that greater than a safe mass was involved, but a sufficient number of controls that were lost were restored within 4 hours. In accordance with Westinghouse Operating License (SNM-1107), paragraph 3.7.3 (c.5b), this event satisfies the criteria for a 24-hour notification. Summary of Activity All pumpouts to bulk storage tanks were stopped immediately upon recognition. This action was initiated by operators monitoring system performance. Samples for grams U-235/liter, pH, and %free acid were taken to ensure the tanks were in specification. Before the end of the shift, sample results for grams U-235/liter, pH, and %free acid were confirmed to be acceptable. At the beginning of each shift, operators are being informed of the incident. The procedure is being modified immediately to incorporate an additional peer check. Independent locks will be installed to require separate individuals to unlock the valve prior to pumpout.

Conclusions Loss of double contingency protection occurred. At no time was the health or safety to any employee or member of the public in jeopardy. No exposure to hazardous material was involved. The Incident Review Committee (IRC) determined that this is a safety significant incident in accordance with governing procedures. Notification was the result of an event, not a deficient NCS analysis. A causal analysis will be performed.

ENS 4088821 July 2004 13:00:00Response4-Hour 91-01 Nrc Bulletin Notification Due to Adu in Non-Favorable Geometry Nitrogen Accumulator Tank

Facility: Westinghouse Electric Company, Commercial Fuel Fabrication Facility, Columbia SC, low enriched (less than or equal to 5.0 wt.% U-235) PWR fuel fabricator for commercial light water reactors. License: SNM-1107.

Time and Date of Event: July 21, 2004, 0900

Reason for Notification: During a highly unusual upset condition on Conversion line 3, ADU powder backed up in the elevator and hot oil dryer. Subsequently, the ADU backed up into the dryer filter housing, crushing stainless steel filter frames and opening a path via dual flexible lines to a non favorable geometry nitrogen accumulator tank. The tank normally serves as a nitrogen gas accumulator/heater to provide heated nitrogen to pulse/clean the bag filters in the dryer filter housing. No similar event has ever occurred in the history of the facility.

In accordance with Westinghouse Operating License (SNM-1107), paragraph 3.7.3 (b.3), this event satisfies the criteria for a 4-hour notification, specifically, any determination that a criticality safety analysis or evaluation was deficient, or that a particular system was not previously analyzed.

As Found Condition: 10.5 kg of dry material (primarily ADU) was removed from the nitrogen accumulator tank.

Summary of Activity: - The affected line remains shutdown until all equipment is cleaned out. - The nitrogen accumulator tanks on all other Conversion lines have been inspected. No evidence of ADU powder has been found.

Conclusions: - This particular tank was not previously analyzed for criticality safety. - There was less than a critical mass of SNM involved. - At no time was the health or safety to any employee or member of the public in jeopardy. No exposure to hazardous material was involved. - The Incident Review Committee (IRC) has determined that this is a safety significant incident in accordance with governing procedures. - A causal analysis will be performed. The licensee will inform the NRC Headquarters Criticality Specialist and the NRC Region 2 Office.

ENS 408557 July 2004 21:00:00ResponseNrc Bulletin 91-01 - 4 Hour Report

The following was submitted via email: Reason for Notification A canvas lined cart was found in the UF6 (Uranium Hexafluoride) bay. The cart dimensions met the criteria for a non favorable geometry (NFG) container however slits had been cut into the bottom of the cart. The presence of the slits makes it questionable as to whether or not this is a true NFG. Taking a conservative approach and assuming that the cart is an NFG, its presence in the Chemical area is prohibited by SNM-1107, Section 6.1.4 without a nuclear criticality safety analysis. In accordance with Westinghouse Operating License (SNM-1107), paragraph 3.7.3 (b.2), this event satisfies the criteria for a 4-hour notification. Specifically, any determination that a criticality safety analysis or evaluation was deficient, or that a particular system was not previously analyzed; and that less than two unlikely, independent, and concurrent changes in process conditions would be required before a criticality accident would be possible. As Found Condition An NCS (Nuclear Criticality Safety) Engineer was notified by a member of the EH&S (Environmental Health and Safety) Department that a canvas cart was in the UF6 bay. The canvas cart had several slits approximately five inches in length cut in the bottom that would preclude the build-up of liquid materials. There was no process equipment in the general area where the cart was located. There was no SNM (Special Nuclear Material) in the cart and the cart was not a part of any existing process. Summary of Activity

 -The cart was dismantled immediately.
 -NCS notified NRC Region II of the cart.

Conclusions

 -This particular system was not previously analyzed for criticality safety.
 -There was no SNM involved.
 -At no time was the health or safety to any employee or member of the public in jeopardy.  No exposure to hazardous material was involved.
 -The Incident Review Committee (IRC) has determined that this is a safety significant incident in accordance with governing procedures.
 -A causal analysis will be performed.

The Licensee notified Region 2 (Ayres, Crespo).

ENS 407934 June 2004 22:00:00ResponseLicensee Reported a 4 Hour 91-01 Response BulletinMaterial accumulation discovered in a 55-gallon drum. The 55-gallon drum was used as a knock-out pot for moisture condensate during high-pressure nitrogen drying of clean UF6 cylinders undergoing re-certification. In accordance with Westinghouse Operating License (SNM-1107), paragraph 3.7.3 (b.2), this event satisfies the criteria for a 4-hour notification. Specifically, any determination that a criticality safety analysis or evaluation was deficient, or that a particular system was not previously analyzed; and that less than two unlikely, independent, and concurrent changes in process conditions would be required before a criticality accident would be possible. During a normal process hazards assessment an NCS Engineer was informed of a 55-gallon drum in the cylinder re-certification process. The drum was found to contain approximately 28 kilograms of dry material. Laboratory analyses determined a maximum concentration of 53.5 weight percent uranium in the form of uranyl fluoride. This corresponds to a uranium mass of approximately 15 kilograms. UF6 cylinders contain virtually no uranium at the time they undergo drying in the cylinder re-certification process. Preliminary investigation has revealed that the drum was inspected from 1993 to 1996 and repeatedly found to contain no solid accumulation before the inspections were discontinued. Cylinder re-certification was not in operation at the time of discovery. NCS formally notified Operations not to operate cylinder re-certification. The drum was removed from the system and inspected. The material was removed from the drum, sampled, and analyzed. This particular system was not previously analyzed for criticality safety. Much less than a critical mass was involved. At no time was the health or safety to any employee or member of the public in jeopardy. No exposure to hazardous material was involved. The Incident Review Committee (IRC) has determined that this is a safety significant incident in accordance with governing procedures. A causal analysis will be performed.
ENS 405674 March 2004 20:00:00Response24-Hour Notification - Bulletin 91-01 Criticality Control

A review of incinerator data indicated higher than expected accumulations and concentrations of uranium bearing material in the incinerator off-gas system. Criticality was not possible because the mass corresponding to each concentration was below the minimum critical mass. Controlled Parameters: The safety basis for the incinerator off gas-system states that criticality is not credible. This was based on minimal expected carryover and low concentrations of uranium from the incinerator to the off -gas system. The uranium concentrations in the off-gas system were expected to be well below the (deleted) concentration criticality limit for an infinite mass. A criticality would be possible in the off-gas system only if a minimum critical mass for a corresponding uranium concentration accumulated in a critical configuration with sufficient moderator. Because higher than expected accumulation and concentration of uranium bearing material was detected in the incinerator off gas system, this 24-hour notification is being made. Summary of Activity: 1) Incinerator was shut down; 2) The off-gas system is being inspected; 3) Samples from the off-gas system are being obtained for analysis. Conclusions: 1). The bounding assumptions for concentration and carryover were exceeded; 2). At no time was there any risk to the health or safety of any employee or member of the public. No exposure to hazardous material was involved & 3). The Incident Review Committee (IRC) determined that this is a safety significant incident in accordance with governing procedures. A formal causal analysis will be performed. The licensee will be notifying NRC Region III.

  • * * UPDATE AT 1346 EST ON 3/9/04 SNYDER TO GOTT * * *

The licensee sent the following addendum via facsimile: Reason for Addendum: Higher than expected concentration of uranium bearing material detected in the incinerator ash. The ash from the lower chamber of the incinerator is lifted via a bucket elevator and dumped into a mill feed hopper and then into a fitzmill. As Found Condition: A review of incinerator data indicated higher than expected concentrations of uranium in the incinerator ash. Controlled Parameters: The safety basis for the ash handling system (elevator and fitzmill) states that criticality is not credible based on the ash remaining below 21.6 weight percent uranium. Summary of Activity: -In addition to the previous activities, the formal root cause team has initiated their investigation. -The incinerator ash elevator and fitzmill safety basis is being re-evaluated. Conclusions: -The bounding assumption for concentration was exceeded. -At no time was there any risk to the health or safety of any employee or member of the public. -No exposure to hazardous material was involved. -The ash handling aspect will be incorporated into the formal causal analysis. Notified NMSS (Psyk) and R2D) (Ayres).

ENS 4044012 January 2004 20:45:00Response24 Hour Notification Bulletin 91-01 Criticality ControlReason for Notification: Thirteen polypaks of uranium powder were dumped into a bulk container without a documented visual inspection of the bulk container. A visual inspection is performed prior to introducing SNM into a bulk container. Upon recognizing that the documentation was missing, the operator confirmed that a visual inspection had been performed prior to introducing SNM, but had not been documented. The operator then re-inspected the bulk container and found no trace of moderator. The powder dumped into the container was previously documented to contain leas than 0.3 weight percent moisture. Double Contingency Protection: Double contingency protection for the ADU Bulk Blending System is assured by preventing moderator from entering a bulk container. Empty bulk containers are inspected for the presence of moderator prior to introducing SNM. Failure to document the inspection left less than previously documented double contingency protection for the system. In accordance with Westinghouse Operating License (SNM-1107), paragraph 3.7.3 (c.5b), this event satisfies the criteria for a 24-hour notification. Summary of Activity: Bulk blending operations were discontinued. Training was performed for each shift prior to resuming operations. Conclusions: Less than previously documented double contingency protection remained. At no time was the health or safety to any employee or member of the public in jeopardy. No exposure to hazardous material was involved. The Incident Review Committee (IRC) determined that this is a significant incident in accordance with governing procedures. A causal analysis will be performed.
ENS 4025516 October 2003 19:30:00Response24 Hour Bulletin 91-01 Notification from Westinghouse Columbia Fuel FacilityDouble Contingency Protection: Double contingency protection for the ADU Bulk Blending System is assured by (1) preventing moderator from becoming available to a bulk container, and (2) preventing moderator from entering a bulk container. The first contingency did not occur because the moderator was never available to a bulk container. Moderator is prevented from entering a bulk container by preventing high moisture polypaks from being dumped into the bulk container. The polypaks are processed through a scan and dump interlock, which prevents unacceptable polypaks from being dumped. The software malfunction left less than previously documented double contingency protection for the system. In accordance with Westinghouse Operating License (SNM-1107), paragraph 3.7.3 (c.5a), this event satisfies the criteria for a 24-hour notification. As Found Condition: See Reason for Notification above. Summary of Activity: Immediately after all packs were dumped into the bulk container to complete the blend of material, Operations noticed that the packs had not been denoted as "consumed" by the data base, and notified the computer system administrator and Nuclear Criticality Safety. The computer system administrator stopped all dumping operations. The computer system administrator immediately checked all packs that had been dumped into the blend. All moisture values were acceptable. All operations that use the same PLC interface program for criticality controls were stopped. Conclusions: Less than previously documented double contingency protection remained. All moisture values for the material involved were acceptable, and the total amount of moderator in the blend was very low, far less than criticality limits. At no time was the health or safety to any employee or member of the public in jeopardy. No exposure to hazardous material was involved. The Incident Review Committee (IRC) determined that this is a safety significant incident in accordance with governing procedures. A causal analysis will be performed.
ENS 4024614 October 2003 11:30:00Response24-Hour Nrc 91-01 Bulletin Report Involving Improper Mass ControlImproper Filling of Dry Combustible Trash Drum Facility: Westinghouse Electric Company, Commercial Fuel Fabrication Facility, Columbia SC, low enriched less then or equal 5.0 wt.% U-235) PWR fuel fabricator for commercial light water reactors. License: SNM-1107. Time and Date of Event: October 14, 2003 Reason for Notification: Dry combustible trash was placed into a single 55-gallon drum without proper mass control. Dry combustible trash drums are positioned on scales for filling. An operator removed a single drum from a scale and then filled the drum with dry combustible trash. The filling of drums on scales prevents exceeding the critical mass limit of (DELETED). The scales actuate a visual alarm at 66 lbs.; and visual and audible alarm at 90 lbs. If the 66 lbs. limit is reached, operators are required to remove trash from a drum. If the 90 lbs. Limit is reached, operators are required to remove trash and write a Redbook. Double Contingency Protection: Double contingency protection for dry combustible trash is assured by preventing (DELETED) of UO2 from becoming available to a single combustible trash drum, and preventing the total weight of a drum from exceeding the (DELETED). Criticality limit. The removal of the drum from the scale and subsequent filling left less than previously documented double contingency protection for the system. In accordance with Westinghouse Operating License (SNM-1107), paragraph 3.7.3 (c.5a), this event satisfies the criteria for a 24-hour notification. As Found Condition: During a routine checking of drums for spacing (i.e., U-235 gram counts), a second operator noticed that a dry combustible trash drum had a net weight of 95 tbs. The operator recognized that a drum weight of 95 lbs. Exceeded the scale limit of 90 lbs. and generated the required Redbook. The drum indicated an assay value of 5.285 grams of U-235. Summary of Activity: - When the second operator found the drum, it was placed on hold. Both process engineering and EH&S were notified. - The drum contents were examined and no improper material types were found in the drum. It was also determined that the material was not compacted. - The drum was weighed and assayed and found to match the values on the drum label. Conclusions: - Less than previously documented double contingency protection remained. - Less than a critical mass was involved. - At no time was the health or safety to any employee or member of the public in jeopardy. No exposure to hazardous material was involved. - The Incident Review Committee (IRC) determined that this is a safety significant incident in accordance with governing procedures. - A causal analysis will be performed. The licensee will inform the Region 2 Office.
ENS 4015212 September 2003 14:32:00ResponseImproper Scanning of Lead Rods for the Product Engineering LaboratoryNRC BULLETIN 91-01 24 HOUR NOTIFICATION FACILITY: Westinghouse Electric Company, Commercial Fuel Fabrication Facility, Columbia SC, low enriched (<5.0 wt,% U-235) PWR fuel fabricator for commercial light water reactors. License: SNM-1107. TIME AND DATE OF EVENT: April 4, 2001 - -- September 5, 2003 REASON FOR NOTIFICATION: Lead-filled rods in a small number of replica fuel assemblies were scanned using an improper instrument. The rods were to be verified as free of uranium prior to delivery to the Product Engineering Lab. The verification is accomplished by either scanning each individual rod with a hand-held instrument or scanning an assembly with a combination of a thimble tube probe and an external hand-held instrument. A few of the hand-held scans were performed with a marginal instrument. DOUBLE CONTINGENCY PROTECTION: Double contingency protection for the VIPER test loop vessel is assured by preventing uranium with greater than 1.0 weight percent uranium-235 from entering the Product Engineering (PE) Lab and preventing that uranium from entering the VIPER test loop vessel. Although lead-filled rods are not tested in the VIPER test loop, the improper scans left less than previously documented double contingency protection for the system. In accordance with Westinghouse Operating License (SNM-1107), paragraph 3.7.3 (c.5), this event satisfies the criteria for a 24-hour notification. AS FOUND CONDITION: See "Reason for Notification" above. NCS detected the absence of a procedure number listing during a normal special routing review. Inquiries led to the discovery that the incorrect instrument was being used to scan lead-filled rods. It was subsequently determined that the response of the instrument used was inadequate to reliably detect a single uranium rod mixed with lead-tilled rods. The initial investigation revealed a weakness in the procedure structure for scanning lead-filled rods. The procedure steps for scanning lead-filled rods are contained in a procedure for transfer and release of potentially contaminated equipment or materials and not addressed in the instrument procedures. SUMMARY OF ACTIVITY: 1). An improved procedure is now in place requiring that all lead-filled rods be individually scanned with the appropriate instrument. 2). All health physics personnel have been trained on the new procedure and proper instrument. CONCLUSIONS: 1). Loss of double contingency protection occurred. 2). At no time was the health or safety to any employee or member of the public in jeopardy. No exposure to hazardous material was involved. 3). The Incident Review Committee (IRC) determined that this is a safety significant incident in accordance with governing procedures. 4). Notification was the result of a weakness in the procedure structure, not a deficient NCS analysis. 5). A causal analysis will be performed.