ML23164A203

Urenco USA (Uusa) - Nuclear Regulatory Commission Special Inspection Report Number 07003103 2023-007

ML23164A203
Person / Time
Site:	07003103
Issue date:	06/15/2023
From:	Masters A NRC/RGN-II/DFFI
To:	Padgett W Louisiana Energy Services, URENCO USA
References
IR 2023007
Download: ML23164A203 (20)

Text

June 15, 2023 EN 56484 Mr. Wyatt Padgett Compliance and Licensing Manager Louisiana Energy Services dba Urenco USA (UUSA)

P.O. Box 1789 Eunice, NM 88231

SUBJECT:

URENCO USA (UUSA) - NUCLEAR REGULATORY COMMISSION SPECIAL INSPECTION REPORT NUMBER 07003103/2023-007

Dear Mr. Padgett:

On May 18, 2023, the U.S. Nuclear Regulatory Commission (NRC) completed its initial assessment of a loss of safety controls event, which occurred on April 21, 2023, at the Louisiana Energy Services facility. Based on our initial assessment, an inspection team was sent to your site on May 8, 2023. The purpose of the inspection was to inspect and assess the facts and circumstances surrounding a loss of safety controls credited in the facilitys Integrated Safety Analysis (ISA) summary document. The enclosed report documents the results of the NRC Special Inspection (SI) conducted from May 8 - May 18, 2023. No violations of NRC requirements are documented in the enclosed report. Any potential enforcement actions resulting from this event will be addressed in future inspection reports.

This event was reported to the NRC Operations Center on April 21, 2023, as Event Notice (EN) 56484, in accordance with the requirements of Title 10 of the Code of Federal Regulations (10 CFR) Part 70, Appendix A, (a)(4) - An event or condition such that no items relied on for safety, as documented in the ISA summary, remain available and reliable, in an accident sequence evaluated in the ISA, to perform their function. The EN was subsequently updated on April 22 and April 25, 2023.

Based on preliminary information provided by the licensee in EN 56484, the NRC determined that an SI was the appropriate level of regulatory response to obtain additional information to fully assess the significance of the event. The SI objectives were to: (1) develop a clear understanding of circumstances leading to a loss of all safety controls, (2) review and evaluate the licensees completed and planned corrective actions, (3) review and evaluate the adequacy of the licensees implementing procedures, (4) review and evaluate the licensees processes for ensuring required controls are in place prior to commencement of work activities, (5) determine if personnel involved were properly trained, and (6) review recent corrective actions associated with similar failures to determine if those corrective actions were adequate. The SI consisted of facility walkdowns of areas within the facility, interviews with licensee and vendor staff, and selective document review including procedures and safety analyses. The enclosed report

W. Padgett 2 documents the results of the SI. The inspection results were discussed with you and other members of your staff at exit meetings held on May 9 and May 18, 2023.

In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice and Procedure," a copy of this letter, its enclosure, and your response (if any), will be made available electronically for public inspection in the NRC Public Document Room or from the NRC's Agencywide Documents Access and Management System (ADAMS), accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html. To the extent possible, your response should not include any personal privacy, proprietary, or classified information so that it can be made available to the Public without redaction.

If you have questions, please contact Joel Rivera-Ortiz, Sr. Project Inspector, Projects Branch 1 at (404) 997-4825.

Sincerely, Signed by Masters, Anthony on 06/15/23 Anthony D. Masters, Director Division of Fuel Facility Inspection Docket No. 07003103 License No. SNM-42

Enclosures:

NRC Inspection Report 07003103/2023-007 w/attachment: Special Inspection Charter cc:

w/encl: Distribution via LISTSERV

ML23164A203 X Non-Sensitive X Publicly Available X SUNSI Review Sensitive Non-Publicly Available OFFICE RII/DFFI RII/DFFI RII/DFFI RII/DFFI RII/DFFI NAME T. Vukovinsky M. Greenleaf T. Sippel J. Rivera-Ortiz A. Masters DATE 06/12/23 06/14/23 06/15/23 06/14/23 06/15/23 U.S. NUCLEAR REGULATORY COMMISSION REGION II Docket No.: 07003103 License No.: SNM-2010 Report No.: 07003103/2023-007 Enterprise Identifier: I-2023-007-0003 Licensee: Louisiana Energy Services (LES) dba Urenco USA (UUSA)

Facility Urenco USA Location: Eunice, NM Inspection Dates: May 8 - May 18, 2023 Inspectors: Tom Vukovinsky, Senior Fuel Facility Inspector Michael Greenleaf, Technical Assistant Approved by: Anthony Masters, Director Division of Fuel Facility Inspection Enclosure

SUMMARY

The U.S. Nuclear Regulatory Commission (NRC) continued monitoring the licensees performance by conducting a Special Inspection (SI) at Urenco USA (UUSA), in accordance with the fuel cycle facility inspection program. This is the NRCs program for overseeing the safe operation of licensed fuel cycle facilities. Refer to https://www.nrc.gov/materials/fuel-cycle-fac.html for more information.

List of Violations No violations of NRC requirements are documented in this report. Any potential enforcement actions resulting from the Event Notice (EN) 56484 will be addressed in future inspection reports.

Additional Tracking Items Type Issue Number Title Report Status Section URI 07003103/2023-007-01 Lack of Implementation of 88003 Open Safety Controls for an Analyzed High Consequence Event URI 07003103/2023-007-02 Evaluation of the Licensees 88003 Open Root Cause Evaluation and Corrective Actions to Prevent Recurrence WER 07003103/2023-002-00 IROFS50 Crane Swing 88003 Closed Controls Not Established (EN56484) 2

REPORT DETAILS Event Summary During this inspection period, the licensee was conducting routine operating activities. On April 21, 2023, UUSA was staging a construction crane to be used for chiller replacement work planned for the following week and failed to implement all required safety controls prior to operating the crane. As reported in EN 56484, dated April 21, 2023, the crane was properly permitted to be staged inside the Controlled Access Area (CAA) but was not properly permitted for operation. The crane was staged just south of Separation Building Module (SBM)-1003 which is an area of concern. Upon discovering the condition, the vehicle of concern was placed in a safe position and all crane activities were halted under licensee Stop Work Memorandums until an investigation of the event is completed. Additional details about the information used for the event assessment and the basis for the Special Inspection are included in the Attachment to this report.

OTHER AREAS IP 88003 - Reactive Inspection for Events at Fuel Cycle Facilities The inspection activities completed for each item in the attached Special Inspection Charter are discussed below.

1. Develop a clear understanding of circumstances leading to a loss of all safety controls to mitigate the event (Charter items 1, 2 and 3)

a. Inspection Scope The inspectors conducted walkdowns of barriers/postings placed in support of item relied on for safety (IROFS) 50f/g establishment as well as walkdowns of the area of concern (AOC), including internal and external areas of the Separations Building Module (SBM) 1005 UF6 handling area (figures 1 and 2). The inspectors also conducted walkdowns of the crane movement path used to bring the crane into the CAA and reviewed the crane and supporting vehicle placement staged near the AOC in accordance with OP-3-1000-19, IROFS50f and 50g External Crane Permit and Barrier Control. The inspectors conducted walkdowns of various site areas throughout the facility to verify that similar hazards did not exist without required controls applied.

The inspectors conducted interviews with UUSA staff, primary vendor, and sub-contractor personnel knowledgeable of the event to assess their understanding of the requirements, roles, and responsibilities for Integrated Safety Analysis (ISA) accident sequence OC4-1, UF6 release caused by uncontrolled external crane load impact with an operating area of concern. The inspectors also interviewed UUSA project management personnel responsible for developing and coordinating the planned construction activities to assess the level of knowledge with WC-3-1000-02, Work Package - Initiation through Closure, Rev. 43 and WC-3-1000-06, Control of Vendor/Contractor Supported Work, Rev. 6. Additionally, the inspectors interviewed operations personnel including operators, Shift Managers, Operations management staff, and licensing staff to assess their level of knowledge of IROFS 50f/g requirements and processes utilized for establishing and monitoring safety controls in accordance with OP-3-1000-19, IROFS50f and IROFS50g Construction Crane Permit and Barrier 3

Control, Rev. 9, OP-3-1000-24, Managing IROFS50 Series Areas of Concern, Rev. 6, OP-3-1000-01, Conduct of Operations, Rev. 41, and LS-3-1000-05, Notifications and Event Reporting, Rev. 20.

Figure 1 - Crane view (from East side) and AOC (SBM to North)

Figure 2 - Crane view (from West side) and AOC (SBM to North) 4

The inspectors reviewed documents; conducted interviews with UUSA staff, management personnel, and vendors/subcontractors; reviewed documents and log records; and viewed video recordings to develop a timeline of events provided below:

(All times are in local Mountain Standard Time - MST):

April 21, 2023 Operations personnel were under the assumption throughout the morning of Friday, 4/21, that the crane would enter the CAA and be parked with appropriate barriers installed and controlled by Operations. No further activities were to take place until Monday, 4/24, when the remainder of the safety barriers/spotters were to be put in place for the lift activity.

Vendor personnel and some non-operations licensee personnel were under a different assumption that the crane would be brought into the CAA and set up for activities to resume on Monday, 4/24. Part of the setup of the crane would be the installation of counterweights which require the crane boom to be operated to lift the counterweights from the trailers to the crane. These assumptions and miscommunications carried forward throughout the morning prior to the event occurring as detailed below.

0700-0715 Project Manager (PM), vendor staff, and Shift Manager (SM) conduct pre-job brief in the control room. Work Order (WO) obtained to move crane into the CAA. The Work Control Manager (WCM) and vendor personnel discuss setup of the crane, including the installation of counterweights; however, the PM and SM had stepped away and were not present during this discussion. No specific details provided on how counterweights were to be installed. WCM believed the counterweights would be installed with a forklift (assumption). WCM authorizes crane movement permit.

0745-0800 Compliance Manager (CM) had questions about the crane being moved into the CAA and WCM discussed that no lifts would occur. The WCM was under the assumption that a forklift was going to be used to move the counterweights. It was decided to bring the key to the SM after moving the crane into place so it could not be used until the operating permit could be authorized with no-swing zone in place (on Monday 4/24). PM agreed to this plan.

0830-0900 Operations informed Security that they had permission to allow crane into CAA. CM arrived and reviewed WO, questioning spotter process and explained spotters should walk with crane. Also discussed signage on barriers. Vendor personnel explained barriers would be placed and signage affixed on Monday (4/24). SM informed the vendor that is how it had been done previously. Later decided Operations would install signage and "control" the crane and SM would hold keys until lift.

0945 Truck trailer with chiller enters the CAA 5

0950 PM meets with vendor personnel and CM for pre-job brief. Verified movement permit and that the vendor signed onto the WO and spotter form. Discussed keeping spotters on until IROFS50 barriers were placed and approved by Operations. CM questions as to how many permits were needed for entire evolution (i.e., crane into the site, lifting the load, and removal of crane).

1000-1045 Two trailers with counterweights brought into the CAA and staged at the lift site. CM meets with Operations personnel over questions about the WO. The WO was revised (due to number of permits required) and an Event Report (EV) issued over questions about the WO.

1100 Crane brought into the CAA and moved to the lift site. Two spotters were in place during crane movement and vendor staff moved barriers in front and behind the crane with a forklift.

1100-1145 Operations went to the crane site area and placed the IROFS50 signs on the concrete barriers. Operations, PM, and vendors reviewed the permit and Operations signed Section C of the crane permit - IROFS Control Boundary Verification. The WO was taken by Operations staff to the control room. The two IROFS50g spotters stayed until barriers signed off.

PM authorized spotters to leave after IROFS barriers were in place and posted. Crane started extending outriggers as part of setup.

1200 Spotters leave job site (approximate) 1200-1300 Rigging installed on crane and crane boom was used to move counterweights from trailers and attach them to the crane. No spotters or no-swing zone barriers were in place as required by IROFS50f/g. Crane operators were under the assumption that installing the counterweights were part of crane setup and not the lift activity. Crane boom was briefly moved into the no-swing zone to install counterweights.

1300 Crane key brought to the control room by vendor personnel as previously briefed to prevent any crane operations over the weekend.

1315-1330 SM has a discussion with pervious operations personnel on how to fill out WO for IROFS50f/g due to their unfamiliarity with the paperwork. During this discussion it was pointed out that the crane boom was seen moving previously. Container Handling Supervisor dispatched to verify that the crane boom had in fact been moved. Container Handling Supervisor verifies that the crane boom had been used to install the counterweights.

1340-1345 CM, and other senior staff enter the control room, and a discussion is held concerning IROFS50f/g availability and reportability.

1345 Time of discovery of IROFS50f/g inoperability established, and instructions given to licensing personnel to prepare a 1-hour report to the NRC.

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1424 A 1-hour report is provided to the NRC in accordance with 10 CFR 70 Appendix A(a)(4), An event or condition such that no IROFS, as documented in the ISA summary, remain available and reliable, in an accident sequence evaluated in the ISA. The NRC documents this report as EN 56484. At this time, Operations and senior management believe that spotters were still at the jobsite during the crane boom movement (assumption, because they knew they were at the jobsite earlier). Report was issued conservatively stating that both IROFS50f and IROFS50g were inoperable, however, it was believed that spotters were in place and exercised appropriate control of the evolution to restrict its movement and not to swing into an AOC.

1424+ Post job brief was held with interested parties to determine the details of the event. CM instructs engineering and operations personnel to review IROFS50f/g to determine exact requirement to fulfill these IROFS.

April 22, 2023 1501 Discussions were held the night of 4/21 and the day of 4/22 concerning the requirements of IROFS50g. As a result of these discussions, it was decided that an update to the EN would be made. At 1501, the NRC was contacted and EN 56484 was updated from 10 CFR 70 Appendix A(a)(4) to Appendix A(b)(2), Loss or degradation of IROFS that results in failure to meet the performance requirement of § 70.61. This changed the EN from a 1-hour report to a 24-hour report. UUSA had determined that IROFS50g was operable and adequately implemented due to IROFS50g spotters being at the lift site during crane boom movement (assumption, not verified).

April 24, 2023 Stop Work memo issued by senior management to Stop Work for all activities using Site Projects and Strategic Projects Contractor Oversight.

This Stop Work was being implemented in response to EV 160170, Crane performed lift without proper lift zone control.

Stop Work memo issued by senior management to Stop Work for all IROFS50a/h, IROFS50b/c, and IROFS50f/g activities. This Stop Work was being implemented in response to EV 160170, Crane performed lift without proper lift zone control.

Discussions were held with Licensing and Operations personnel concerning the spotters. The approved spotters used for the crane movement on 4/21 were interviewed and it was determined that following placement of barriers in front and behind the crane to prevent movement, and following Operations control of these barriers, the spotters were relieved of their duties. No spotters were present during the crane boom movement to install counterweights contrary to what was previously believed.

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April 25, 2023 1501 UUSA determined that contrary to the initial reports, the required spotters were not present while operation of the crane occurred. As a result, IROFS50f/g were determined not to be available and reliable. The appropriate reporting criteria for EN 56484 was changed to 10 CFR 70 Appendix A(b)(2) back to Appendix A(a)(4) as initially reported on 4/21.

b. Conclusion

The inspectors were able to develop a timeline of the sequence of events to understand the sequence of events leading to the loss of all safety controls for OC4-1. Evaluation of the loss of safety controls are further discussed in section 4 of this report. The inspectors evaluated the licensees immediately corrective actions and corrective actions identified in the Stop Work Memorandums. The inspectors assessed the Stop Work Memorandums address the deficiencies of the identified event to prevent a recurrence of the condition, however, the effectiveness of the Corrective Actions to Prevent Recurrence (CAPRs) and other long term corrective actions will need to be evaluated (see Section 3).

2. Determine if personnel involved in the implementation of the IROFS 50f and 50g were properly trained (Charter item 4)

a. Inspection Scope The inspectors conducted interviews with vendor personnel and licensee employees from the operations, engineering, licensing, and security departments to assess training and level of knowledge of IROFS50f and IROFS50g. The inspectors reviewed training materials associated with IROFS50f and IROFS50g.

Prime vendor personnel were formally trained on IROFS50f and IROFS50g requirements associated with this crane lift prior to commencing work activities; notably, the placement of barriers for IROFS50f and the use of flaggers required by IROFS50g. The two qualified flaggers were current in their qualifications as spotters and had signed onto the WO as required by OP-3-1000-19.

The sub-contractor was not formally trained on IROFS50f and IROFS50g requirements associated with this crane lift prior to commencing work activities.

The crane operator was aware of the AOC; however, no specific training was provided for the IROFS use and implementation.

The PM was trained and qualified on IROFS50f and IROFS50g requirements associated with this crane lift prior to commencing work activities.

Operations supervisors and managers were formally trained on IROFS50f and IROFS50g requirements associated with this crane lift prior to commencing work activities.

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b. Conclusion

The licensees training on IROFS50f and IROFS50g was not comprehensive for all individuals involved in the work activity. Specifically, the subcontractors were not aware of the IROFS other than in a general idea that barriers and signs needed to be installed.

The inspectors noted that the SM received Just-in-Time training for IROFS50b/c and IROFS50 following the event in March 2022. The inspectors also noted that although plant personnel were trained on IROFS50f and IROFS50g, the infrequent use and implementation of these IROFS contributed to the event. The inspectors noted that formal training and qualification requirements were assigned as corrective actions in the Stop Work Memorandum.

3. Review and evaluate the licensees completed and planned corrective actions, extent of condition evaluation, and implementation of any compensatory measures (Charter item 5)

a. Inspection Scope The inspectors reviewed immediate corrective actions taken by the licensee upon discovery of the condition on April 21, 2023, to include ensuring that the crane keys were being controlled to prevent operation and implementation of the initial of Stop Work Memorandums.

Specifically, the inspectors reviewed actions taken by the licensee against actions in accordance with Operational Requirements Manual, (ORM) 50f-50g, Administratively Control Load Movement of External Cranes, Rev. 6. The inspectors confirmed that UF6 cylinder operations were being conducted in the AOC during the time the crane was being operated within the CAA. The inspectors determined that the decision to use the cranes boom to install the counterweights was conducted without the WO in hand or being directed by Operations. Upon discovery of the crane use, the SM was unable to execute the appropriate required actions as the crane had already completed installing the counterweights.

The licensee entered the event into the corrective action program as EV160170. The inspectors reviewed the assigned interim corrective actions as prescribed in EV160170 to include two Stop Work Memorandums. These actions included (1) Stand down held with all individuals that provide contractor oversight for Site Projects and Strategic Projects; (2) Every person associated with project contract oversight shall be interviewed and evaluated to ensure their understanding of key safety functions; (3) Review and modify IROFS50f/g implementing procedure OP-3-1000-19; (4) Implement process to ensure IROFS surveillances that are not performed on a consistent basis are performed correctly and understood; and (5) Documented extent of condition will be performed by Operations to ensure compliance with IROFS50. Completion of these actions, along with agreement by the Chief Nuclear Officer (CNO) will be required to lift the stop work(s) regarding implementation of IROFS50 series of controls.

The inspectors noted that UUSA has implemented an IROFS50f/g Recovery Team. The purpose of the Recovery Team is to determine a resolution to issues associated with the implementation of IROFS50f/g that will prevent reoccurrence, allow for safe operation of 9

the plant, recommencement of projects on site, and restore regulatory compliance.

Additionally, UUSA has commenced a Root Cause Evaluation (RCE) into the event.

The RCE will determine the root cause for the failure to implement IROFS50f/g along with determining CAPRs and an effectiveness review of previous root cause (EV149740) associated with IROFS50b/c failure.

b. Conclusion

The inspectors reviewed actions taken by the licensee against actions required in accordance with ORM 50f-50g. The licensee is in the process of conducting their RCE and associated actions. Based on the scheduled milestones and completion date of the RCE, Unresolved Item (URI) 07003103/2023-007-02, Evaluation of the Licensees Root Cause Evaluation and Corrective Actions to Prevent Recurrence is being opened to review and evaluate the RCE and associated corrective actions.

Unresolved Evaluation of the Licensees Root Cause Evaluation and 88003 Item Corrective Actions to Prevent Recurrence (Open) URI 07003103/2023-007-02

Description:

The licensee identified and reported a condition in which no IROFS were available or reliable, to the NRC in accordance with 10 CFR 70 Appendix A(a)(4) on April 21 and 25, 2023, based on the as found conditions associated with crane operations. An RCE has been initiated to determine the root cause of the incident and develop CAPRs. Once complete, the NRC will review the licensees evaluation of the event and any proposed corrective actions, and the extent of condition evaluation.

Planned Closure Actions: The NRC will assess the licensees evaluation of the event and any proposed corrective actions and the extent of condition evaluation.

Licensee Actions: Provide completed RCE, identified CAPRs and other associated corrective actions, and the extent of condition.

Corrective Action

References:

EV160170

4. Review and Evaluate licensee processes for ensuring required controls are in place and available and reliable prior to commencement of work activities (Charter item 6)

a. Inspection Scope The inspections reviewed NEF-BD-50f, Administratively Control Proximity of External Crane Loads, which administratively controls proximity of external cranes inside the CAA to prevent release of UF6. This procedure establishes: (1) safe distance with the use of barriers; or (2) a No-Swing Zone when the crane is closer than a safe distance from an operating AOC. The No-Swing Zone is defined as the boom swing section containing an AOC plus 30 degrees on either side. The No-Swing Zone is a physical demarcation visible to the operator and spotter.

The inspectors reviewed WO 1000601146, Chiller #4 Placement IROFS50 Crane, associated with the planned activity. The inspectors noted that WO 1000601146 was established as a Quality Level 1 (QL-1) safety requirement to establish the barriers and 10

spotters for IROFS50f and IROFS50g. The inspectors noted that all required personnel were at the pre-job briefing held prior to commencement of the activity and the requires spotters had signed OP-3-1000-19-F-3, Spotter Verification Form. The crane entry permit (OP-3-1000-19-F-1) was filled out and approved by Operations prior to bringing the crane into the CAA in accordance with WO 1000601146.

The WO also had established the Area of Concern and the 30 degree no-swing zone as required by OP-3-1000-19 and ORM 50f-50g. The inspectors noted that although the No-Swing Zone was determined in the WO, the value used for the crane boom length did not consider the maximum crane boom length per the vender manual. The value used was the expected boom length for the lift instead of the maximum boom length to which the crane could extend.

The inspectors noted that WO 1000601146 was only signed off to step 6 of the Detailed Work Instructions/Task List portion of the WO. Step 6 was a hold point to establish IROFS50 barriers and declare them operable by Operations personnel to allow vehicle movement into the CAA. The inspectors noted that the following sections, Crane CAA Entry Permit, IROFS50f Barrier Control Status, Verify Lift Plan Approval Status, No-Swing Zone Markers, and Initiate Lifting Operations, had not been filled out as required by AD-3-1000-02, Procedure Use and Adherence. Additionally, MA-2-1000-01, Conduct of Maintenance step 3.11.3.a states, "Approved procedures and/or work instructions are required prior to and during repair or modification work performed on QA Level 1 equipment." This was not followed during the performance of WO 1000601146.

The SM removed the WO from the field to address issues with the WO concerning the number of tractor trailers staged for the job. The SM went to the control room with the PM to address these issues, but work continued by the vendor without the work package.

The inspectors noted that the crane was properly staged and that barriers were put in place to confine the crane as required by OP-3-1000-19. The barriers were placed in front and behind the crane to prevent its movement and were signed off and accepted by Operations staff as part of WO 1000601146. The inspectors conducted a walk-down of the job site following the event and noted that there was no visible demarcation to indicate the No-Swing Zone which includes the AOC plus 30 degrees on either side.

Through interviews and review of documents, the inspectors noted that once the crane was put in position to support the lift that was planned for April 24, 2023, the WO was returned to the control room. The required spotters that were in place during crane movement to the lift site were dismissed from the work site. The inspectors noted that at this time, the required safety controls for IROFS50f were not properly established (no visible demarcation of the No-Swing Zone) and the spotters required for IROFS50g were not available. Shortly afterwards, the crane boom was used to move the counterweights without IROFS50f or IROFS50g in place contrary to OP-3-1000-19. The movement of the counterweights took approximately 30 minutes to complete. Once Operations staff became aware that the crane had been operated without the IROFS in place, the required notifications were made to the NRC in accordance with LS-3-1000-05. Through interviews conducted with the crane operators, the NRC determined that the crane boom had briefly been moved into the No-Swing Zone to install the counterweights, however, at no time did the boom or any load contact with the AOC.

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The inspectors determined that the Operations staff concluded that IROFS50f/g were not in place at the time of crane movement, and as such, no IROFS were available or reliable to prevent the accident sequence as described in OC4-1. The inspectors reviewed WC-3-1000-02, Work Package - Initiation through Closure, Rev. 43, and WC-3-1000-06, Control of Vendor/Contractor Supported Work, Rev. 6 to verify that licensee oversight of vendor activities is adequately identified and to verify that operations approval to conduct safety related activities is addressed.

The inspectors noted that had OP-3-1000-19 and the WO been properly implemented, the required controls would have been put in place prior to crane boom movement. The inspectors reviewed the corrective actions identified in the Stop Work Memorandums, specifically, the training and establishment of the requirement for written work orders for all contractor activities at the site.

b. Conclusion

The licensee did not have established controls in place (IROFS 50f/g) to support crane lifting activities on April 21, 2023, as per the documented ISA requirements approved at the time. Although no actual consequences occurred as a result of the event, URI 07003103/2023-007-01, Lack of Implementation of Safety Controls for an Analyzed High Consequence Event, is being opened to assess the potential consequences based on evaluation of the hazard, required controls, extent of condition, and any previous instances of non-compliance associated with accident sequence OC4-1 by the licensee.

Unresolved Lack of Implementation of Safety Controls for an Analyzed 88003 Item High Consequence Event (Open) URI 07003103/2023-007-01

==

Description:==

The licensee identified a lack of controls (IROFS50f and IROFS50g) available while a crane was being operated within the CAA. A one-hour NRC notification was made (EN 56464) on April 21, 2023, and subsequently updated on April 22 and April 25, 2023, based on an evaluation of the availability of spotters during the crane lift.

Planned Closure Actions: The NRC will assess the licensees evaluation of the event and applicability of IROFS50f and IROFS50g to determine if a violation exists. The NRC will also review the 60-day report for EN56464 once that report has been issued.

Licensee Actions: Provide detailed investigation of the event, including the root cause, extent of condition, causal factors, the licensees 60-day report, and any previous incidents in which IROFS50f/g were not available and reliable during crane operations.

Corrective Action

References:

EV160170 WER IROFS50 Crane Swing Controls Not Established 88003 (Closed) (EN56484)

WER 07003103/2023-002-00

==

Description:==

On Friday April 21, 2023, UUSA reported:

On April 21, 2023, UUSA was staging a construction crane to be used the following week and failed to maintain procedural compliance while implementing IROFS50f and IROFS50g. The crane was properly permitted and placed inside the CAA but was not properly permitted for 12

operation. At all times the required spotters for IROFS50f and IROFS50g were in place and the movement of the crane was sufficiently controlled to restrict its movement to not swing into an area where damage could occur. However, visual indicators were not established as required by procedure. Spotters were in place and exercised appropriate control.

IROFS50f/g are independent, administrative IROFS that prevent heavy vehicles from damaging equipment that could result in a UF6 release. Both IROFS are required to meet the performance requirement of 10 CFR 70.61.

Work has been stopped and the crane has been demobilized. The plant is in a safe condition.

UUSA is conservatively reporting this event under 10 CFR 70 App. A(a)(4). This issue has been entered into the corrective actions program as EV 160170.

On Saturday, April 22, UUSA updated their report to credit IROFS50g:

"Following a more detailed review, IROFS50g was determined to be operable and adequately implemented. As a result, the appropriate reporting criteria is being changed to 10 CFR 70 Appendix A (b)(2)."

On Tuesday, April 25, UUSA corrected their previous update:

"The operation of the crane has stopped, and it remains south of SBM 1001 [actually SMB 1003].

Contrary to the initial report, the required spotters were not present and controlling the movement of the boom. As a result, IROFS50f/g have been determined not to be available and reliable. The appropriate reporting criteria is being changed to 10 CFR 70 Appendix A (a)(4).

The stop work involving the use of construction vehicles and IROFS50 remains in place. All work performed by site projects has been stopped."

WER 07003103/2023-002-00, "IROFS50 Crane Swing Controls Not Established (EN56484)"

is being closed to URI 07003103/2023-007-01 which will include review of the licensees written follow-up report.

5. Determine whether the licensees causal evaluation of the event is being conducted at an appropriate level (Charter item 7)

a. Inspection Scope The inspectors developed a timeline of events to assess the discovery, identification, and notification of event conditions. The inspectors conducted interviews with vendor personnel and licensee employees from the operations, engineering, licensing, and security departments. The inspectors reviewed LS-3-1000-05, Notifications and Reporting, Rev. 20. The licensee documented the discovery of the condition at 1345 MST and completed the required notification to the NRC per 10 CFR 70 Appendix A (a)(4) at 1426 MST, in EN 56484. The inspectors interviewed Licensing and Operations personnel regarding roles and responsibilities and reviewed the NRC Form 361A, Fuel Cycle and Material Event Notification Worksheet.

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b. Conclusion

The inspectors noted that the event involved a significant condition adverse to quality (SCAQ) which requires an RCE to be initiated in accordance with CA-3-1000-01, Performance Improvement Program, Rev. 51. The licensee has entered the event into their corrective action program as EV160170 and has initiated a RCE to evaluate the root cause and develop CAPRs in accordance with CA-3-1000-01. In addition, the licensee has initiated a Recovery Team to holistically review the event and resolution of issues associated with the implementation of IROFS50f/g items that will prevent reoccurrence, allow for safe operation of the plant, recommencement of projects on site, and restore regulatory compliance.

6. Gather information on other IROFS controls, if any, that could be reasonably credited for the applicable accident sequence to meet the performance requirements of 10 CFR 70.61 (Charter item 8)

a. Inspection Scope The inspectors walked down the as-left condition of the crane and any barriers/signage that was put in place to support the work activity in accordance with WO 1000601146.

Although movement barriers were put in place to prevent the crane from moving into the No-Swing Zone, no visual demarcation was established to alert the crane operator or spotters of the No-Swing Zone as required by IROFS50f. In addition, the two spotters that were initially signed onto the WO were not present when then the crane boom was in operation contrary to IROFS50g. The inspectors interviewed personnel who were at the job site during crane operation to determine roles and responsibilities of each individual and reviewed their qualifications.

b. Conclusion

The inspectors noted that there were no other IROFS controls related to accident sequence OC4-1 detailed in the ISA which were available and reliable at the time of the event.

EXIT MEETINGS AND DEBRIEFS The inspection scope and results were presented to Karen Fili, UUSA President and CEO, and other members of the licensees staff on May 10 and May 18, 2023. The inspectors verified no proprietary information was retained or documented in this report.

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SUPPLEMENTARY INFORMATION

1. Key Points of Contact Licensee personnel Name Title T. Armstrong Day Shift Manager M. Boden Project Manager S. Diggs Operations Manager J. Huber Deputy Operations Engineer D. Hurd Shift Manager E. Kobaly Shift Manager B. Love Licensing Specialist Q. Newell Nuclear Criticality Safety Manager W. Padgett Compliance Manager G. Poortman Senior Project Manager/Root Cause Team Lead D. Rush Maintenance Manager

2. Inspection Procedures Used IP 88003 Reactive Inspection for Events at Fuel Cycle Facilities IP 93812 Special Inspection 15

DOCUMENTS REVIEWED Inspection Type Designation Description or Title Revision or Procedure Date 88003 Corrective Action 160169, 160170, Condition Reports Various Documents 160177, 123013, 160281, 160244, 160282, 160291, 160292, 160306, 160340, 160348, 160351, 160352, 160360, 160380, Miscellaneous Safety Analysis Report Rev. 49 NEF-BD-50f Administratively Control Proximity of External Crane Loads Rev. 9 NEF-BD-50g Administratively Control Movement of External Cranes by Use of Rev. 10 Spotters ORM 50f-50g Administratively Control Load Movement of External Cranes Rev. 6 Procedures AD-3-1000-02 Procedure Use and Adherence Rev. 19 CA-3-1000-01 Performance Improvement Plan Rev. 51 LS-3-1000-05 Notifications and Event Reporting Rev. 20 MA-2-1000-01 Conduct of Maintenance Rev. 7 OC4-1 External Cranes (ISA Summary) Rev. 33b OP-3-1000-01 Conduct of Operations Rev. 41 OP-3-1000-19 IROFS50f and 50g External Crane Permit and Barrier Control Rev. 9 OP-3-1000-24 Managing IROFS50 Series Areas of Concern Rev. 6 WC-3-1000-02 Work Package - Initiation through Closure Rev. 43 WC-3-1000-06 Control of Vendor/Contractor Supported Work Rev. 6 Work Orders 100601146 Chiller #4 Placement IROFS50 Crane 04/21/2023 OP-3-1000-19-F-3 Spotter Verification Form Rev. 9 16

May 1, 2023 MEMORANDUM TO: Thomas Vukovinsky, Senor Fuel Facility Project Inspector Projects Branch 2 Division of Fuel Facility Inspection Michael Greenleaf, Technical Assistant Division of Fuel Facility Inspection Signed by Dudes, Laura FROM: Laura A. Dudes on 05/01/23 Regional Administrator

SUBJECT:

CHARTER FOR SPECIAL INSPECTION AT URENCO USA - SAFETY CONTROLS NOT ESTABLISHED DURING CRANE OPERATIONS (EVENT REPORT 56484)

You have been selected to conduct a Special Inspection (SI) at the Urenco USA (UUSA) facility to assess the circumstances of an event involving the failure to meet the performance requirements in 10 CFR 70.61. Your onsite inspection should begin on May 8, 2023.

A. Basis On April 21, 2023, UUSA was staging a construction crane to be used for chiller replacement work planned for the following week and failed to implement all required safety controls prior to conducting operations. As reported, the crane was properly permitted to be staged inside the Controlled Access Area (CAA) but was not properly permitted for operation. The crane was staged just south of Separation Building Module (SBM)-1003 which is an area of concern.

The accident sequence of concern (OC4-1) involves a crane (through mechanical failure or human error) swinging its load and impacting an area of concern, resulting in damage and a UF6 release with high consequences to the public and workers. To mitigate the risk of this event, two safety controls IROFS50f and IROFS50g are required to be implemented prior to operating the crane. IROFS50f/g are both administrative items relied on for safety (IROFS) that prevent external cranes from damaging equipment that could result in a UF6 release. IROFS50f administratively controls the proximity of external cranes inside the CAA by establishing a safe distance from an area of concern (e.g., UF6 handling areas) using barriers and by establishing a no swing zone. IROFS50g controls the movement of cranes around the area of concern using spotters. The spotters also ensure the integrity of the boundaries of the no swing zone. Both controls are required to be implemented when operating the crane to meet the performance requirements listed in 10 CFR 70.61.

CONTACT: Robert Williams, DFFI/PB1 404-997-4664 Attachment

After staging the crane, the licensee operated the crane to install counterweights for the crane in preparation for chiller replacement work the following week. Neither IROFS50f nor IROFS50g were fully implemented prior to operations commencing. The licensee identified the issue during work planning activities and submitted a one-hour report in accordance with 10 CFR 70 Appendix A(a)(4) on the bases that no IROFS remained available and reliable to meet the performance requirements of 10 CFR 70.61. The licensee subsequently updated the event notification report two more times on April 22, 2023, and April 25, 2023, initially stating that some controls were determined to be available and then again stating that no controls were available.

Region II staff evaluated the deterministic criteria in Management Directive (MD) 8.3, NRC Incident Investigation Program for fuel cycle facilities and Regional Office Instruction 0704 to determine the level of NRC response for this event. The issue of concern potentially met several of the deterministic criteria in ROI-0704 since the event involved an event or condition such that the performance requirements of 10 CFR 70.61 were not met, as documented in the Integrated Safety Analysis summary. The failure to implement both IROFS increased the likelihood of a high consequence event to the extent of not meeting the performance requirements in 10 CFR 70.61.

According to ROI-0704, plant events that result in a very substantial increase in the likelihood of a high consequence event could be considered for an Augmented Inspection or reduced to a Special Inspection if the licensee is taking adequate actions to manage the event. Additionally, per Inspector Manual Chapter (IMC) 2601, events that involve a loss or significant degradation of safety functions such that the performance requirements of 10 CFR 70.61 are not being met should be considered for an SI. Due to the actions taken by the licensee and the NRCs understanding of the issue, the inspection staff recommended that a SI be performed.

B. Scope The SI should focus on an independent assessment of the event as well as licensees performance, response, and evaluation. The scope of the SI shall include but not be limited to the following items:

(1) By the end of the first day on site, make a recommendation as to whether a special inspection is the appropriate NRC response or if an Augmented Inspection Team is warranted.

(2) Conduct a walkdown of the staging area for the crane operations, detailing the proximity to any areas of concern, the types of work activities being conducted both at the areas of concern and the staging site, and the location of any controls that were in place at the time of the event.

(3) Review the circumstances leading up to the event, and to the extent possible, develop a Sequence of Events. Additionally, identify specific details related to the content and accuracy of the licensees notifications of the event to the NRC.

(4) Review appropriate documentation and conduct interviews with personnel involved in the event including the Shift Manager, operators, contractors/subcontractors, project managers and security personnel to determine to what extent personnel were trained on and knowledgeable of the safety controls required to complete the planned activities.

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(5) Review and evaluate the licensees completed and planned corrective actions, extent of condition reviews, and compensatory measures to determine if this supports resumption of normal operations. Additionally, review recent corrective actions associated with similar failures to implement safety controls (e.g., IROFS50b and IROFS50c) when conducting construction activities to determine if those corrective actions were appropriately applied or applicable to the current event.

(6) Review and evaluate licensee processes (site access, work control, etc.) for ensuring required controls are in place and available/reliable prior to commencement of work activities and determine whether those processes were appropriately implemented.

(7) Determine whether the licensees causal evaluation for the event is being conducted at an appropriate level in accordance with procedures and commensurate with the safety significance of the event.

(8) Gather information on other IROFS controls, if any, that could be reasonably credited for the applicable accident sequence to meet the performance requirements in 10 CFR 70.61.

C. Guidance Inspection Procedure (IP) 88003 (Reactive Inspection for Events at Fuel Cycle Facilities Program), provides additional guidance to be used during the conduct of the inspection. Your duties will be as described in IP 88003 and should emphasize fact-finding in its review of the circumstances surrounding the incident. Safety or security concerns identified that are not directly related to the event should be reported to the Region II office for appropriate action.

You will report to the site, conduct an entrance, and begin inspection no later than May 8, 2023. It is anticipated that the onsite portion of the inspection will be completed during the week ending May 12, 2023. You will conduct an exit meeting at the appropriate time. An initial briefing of Region II management will be provided on May 8, 2023, at approximately 4:30 p.m.

EDT. In accordance with IP 88003, you should promptly recommend a change in inspection scope, or escalation, if information indicates that the assumptions used in the MD 8.3 analysis were not accurate. The inspection results will be documented in a Special Inspection Report and should be issued within 45 days of the completion of the inspection. At the completion of the inspection, you should provide recommendations for improving the Fuel Cycle Oversight Process, core inspection procedures, and the SI process based on any lessons learned.

This charter may be modified should you develop significant new information that warrants review.

Docket No. 070-3103 License No. SNM-2010 3