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{{#Wiki_filter:6-,,e,ýOA liýýO+ eAU44-1 ROOT CAUSE REPORT TITLE:         Inadequate response to unplanned environmental tritium releases from Braidwood Station due to weak managerial oversight and the lack of integrated procedural guidance.
{{#Wiki_filter:6-,,e,ýOA liýýO+ eAU44-1 ROOT CAUSE REPORT TITLE:
Unit(s):                             Braidwood Units 1 and 2 Event Date:                         11/30/2005 Event Time:                          11:50 Action Tracking Item Number:         428868 Report Date:                         02/14/06 Sponsoring Manager:               I Janice Kuczynski Investigators:         Position "Jason Eggart     /
Inadequate response to unplanned environmental tritium releases from Braidwood Station due to weak managerial oversight and the lack of integrated procedural guidance.
Braidwood Chemistry Lead Investigator
Braidwood Units 1 and 2 Unit(s):
'Tom Leffler            Root Cause (RC) Qualified Investigator Randy Kalb            Dresden Chemistry Investigator Kim Aleshire          Braidwood EP (ODCM) Investigator Glen Vickers          LaSalle RP Investigator Scott Kirkland        Quad Cities Investigator Jim Crawford        I  BWD CMO RC Qualified Investigator Mike Miller            Braidwood Operations Jeff Burkett          Braidwood Operations Dan Stroh              Braidwood Engineering Carl Dunn              Senior Mentor Executive Summary:
Event Date:
Event Time:
11/30/2005 11:50 428868 02/14/06 Action Tracking Item Number:
Report Date:
Sponsoring Manager:
I Janice Kuczynski Investigators:
"Jason Eggart
'Tom Leffler Randy Kalb Kim Aleshire Glen Vickers Scott Kirkland Jim Crawford Mike Miller Jeff Burkett Dan Stroh Carl Dunn
/
Position Braidwood Chemistry Lead Investigator Root Cause (RC) Qualified Investigator Dresden Chemistry Investigator Braidwood EP (ODCM) Investigator LaSalle RP Investigator Quad Cities Investigator BWD CMO RC Qualified Investigator Braidwood Operations Braidwood Operations Braidwood Engineering Senior Mentor I
Executive Summary:
Reason for Investigation:
Reason for Investigation:
Braidwood Station identified low levels of elevated tritium in the groundwater on and in the vicinity of Braidwood Station property (See Attachment 7 for Map). The presence of these elevated levels exceeds levels specified in Illinois EPA regulations (Attachment 10). The Illinois Environmental Protection Agency (IEPA) groundwater limit for tritium concentration parallels the Federal EPA regulation for annual radiation limits due to drinking water radioactivity. The statutes imply that four (4) mrem would not be exceeded if less than two liters of water at the IEPA limit were.:.
Braidwood Station identified low levels of elevated tritium in the groundwater on and in the vicinity of Braidwood Station property (See Attachment 7 for Map).
The presence of these elevated levels exceeds levels specified in Illinois EPA regulations (Attachment 10).
The Illinois Environmental Protection Agency (IEPA) groundwater limit for tritium concentration parallels the Federal EPA regulation for annual radiation limits due to drinking water radioactivity. The statutes imply that four (4) mrem would not be exceeded if less than two liters of water at the IEPA limit were.:.
ingested daily for a year. In addition, the U.S. Nuclear Regulatory Commission (NRC) provides limnits on liquid effluent releases and how those effluents must be
ingested daily for a year. In addition, the U.S. Nuclear Regulatory Commission (NRC) provides limnits on liquid effluent releases and how those effluents must be


monitored and reported. The NRC has reached a preliminary conclusion that Braidwood may not have satisfied all associated regulations in this regard. When the inspection exit for the current NRC review is completed, any potential violations will be entered into the Braidwood Corrective Action Process. This report provides insights on the causes of these potential violations and associated corrective actions. Additional investigation will be performed commensurate with the content of any such potential violations.
monitored and reported.
The NRC has reached a preliminary conclusion that Braidwood may not have satisfied all associated regulations in this regard. When the inspection exit for the current NRC review is completed, any potential violations will be entered into the Braidwood Corrective Action Process.
This report provides insights on the causes of these potential violations and associated corrective actions. Additional investigation will be performed commensurate with the content of any such potential violations.
Scope of the Review:
Scope of the Review:
The first focus of this root cause investigation is to determine the root cause(s) of and appropriate corrective actions for the unplanned tritium releases from Braidwood Station (See Attachment 1). The Braidwood Tritium Remediation Team has responsibility under Action Request (AR) 435383 for corrective actions to prevent future unplanned tritium releases to the environment and to remediate the existing condition of detectable tritium in groundwater on and in the vicinity of Braidwood Station property. The second focus of this root cause team is to evaluate the effectiveness of Braidwood's response to the Circulating Water (CW) Blowdown (BID) leaks, which deposited tritiated water on the ground during 1998 and 2000 as well as during the smaller volume leaks, which both preceded and succeeded the 1998 and 2000 leaks. If this investigation determines that Braidwood's response actions were not effective, this root cause team will determine the root cause(s) and appropriate corrective actions for those ineffective response actions.
The first focus of this root cause investigation is to determine the root cause(s) of and appropriate corrective actions for the unplanned tritium releases from Braidwood Station (See Attachment 1). The Braidwood Tritium Remediation Team has responsibility under Action Request (AR) 435383 for corrective actions to prevent future unplanned tritium releases to the environment and to remediate the existing condition of detectable tritium in groundwater on and in the vicinity of Braidwood Station property. The second focus of this root cause team is to evaluate the effectiveness of Braidwood's response to the Circulating Water (CW) Blowdown (BID) leaks, which deposited tritiated water on the ground during 1998 and 2000 as well as during the smaller volume leaks, which both preceded and succeeded the 1998 and 2000 leaks. If this investigation determines that Braidwood's response actions were not effective, this root cause team will determine the root cause(s) and appropriate corrective actions for those ineffective response actions.
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OP-AA-106-101-1002, Exelon Nuclear Issues Management, will be revised to: 1) improve Corrective Action Program (CAP) controls of Issues Management teams, 2) utilize the tools and techniques of the Exelon HU-AA-102 and HU-AA-1212, Technical Human Performance Practices and Technical Task Risk/Rigor Assessment, Pre-Job Brief, Independent Third Party Review, and Post-Job Brief procedures, 3) strengthen reporting requirements to station Senior Management, and 4) define station Senior Management responsibilities for oversight and challenge of events and issues from initial identification to final disposition (CAPR 5).
OP-AA-106-101-1002, Exelon Nuclear Issues Management, will be revised to: 1) improve Corrective Action Program (CAP) controls of Issues Management teams, 2) utilize the tools and techniques of the Exelon HU-AA-102 and HU-AA-1212, Technical Human Performance Practices and Technical Task Risk/Rigor Assessment, Pre-Job Brief, Independent Third Party Review, and Post-Job Brief procedures, 3) strengthen reporting requirements to station Senior Management, and 4) define station Senior Management responsibilities for oversight and challenge of events and issues from initial identification to final disposition (CAPR 5).
Extent of Condition:
Extent of Condition:
Exelon Nuclear is evaluating the potential for unplanned tritium releases at each of its facilities, with added emphasis on Pressurized Water Reactors due to tritium production rates. Nuclear Event Report (NER 428868-12) will require all Exelon Sites to take actions to research historical spills and determine if tritium remediation is required. The nuclear industry will be informed of the issue through a Nuclear Network Operating Experience Report (NNOE 428868-13).                   Other spill type (Hazardous Material) response procedures were reviewed and determined to have effective guidance through the Hazmat and Environmental programs (Attachments 2
Exelon Nuclear is evaluating the potential for unplanned tritium releases at each of its facilities, with added emphasis on Pressurized Water Reactors due to tritium production rates. Nuclear Event Report (NER 428868-12) will require all Exelon Sites to take actions to research historical spills and determine if tritium remediation is required. The nuclear industry will be informed of the issue through a Nuclear Network Operating Experience Report (NNOE 428868-13).
& 8). These programs and procedures will receive further review and update to integrate radiological interfaces (CAPR 3).
Other spill type (Hazardous Material) response procedures were reviewed and determined to have effective guidance through the Hazmat and Environmental programs (Attachments 2
& 8).
These programs and procedures will receive further review and update to integrate radiological interfaces (CAPR 3).
4
4


Risk Assessment/ Reportability:
Risk Assessment/ Reportability:
The Nuclear Safety Risk Assessment showed no impact on station operation or response to postulated accident conditions. The event was reportable under Reportability Manual, SAF 1.9, News Release or Notification of Other Government Agencies per 10 CFR 50.73.
The Nuclear Safety Risk Assessment showed no impact on station operation or response to postulated accident conditions.
The event was reportable under Reportability Manual, SAF 1.9, News Release or Notification of Other Government Agencies per 10 CFR 50.73.
Previous Events:
Previous Events:
Since 1996, 17 CW B/D valve leaks were noted in the Braidwood Corrective Action Database and Work Control System as documented in Table 1 of this report in the Events Description Section. Responses varied from a request for a normally scheduled repair to immediate remediation efforts. The best response, which occurred in year 2000, removed water from the spill area, but did not effectively determine the extent of condition for full remediation.
Since 1996, 17 CW B/D valve leaks were noted in the Braidwood Corrective Action Database and Work Control System as documented in Table 1 of this report in the Events Description Section.
Responses varied from a request for a normally scheduled repair to immediate remediation efforts.
The best response, which occurred in year 2000, removed water from the spill area, but did not effectively determine the extent of condition for full remediation.
Condition Statement:
Condition Statement:
In response to an Illinois Environmental Protection Agency (IEPA) inquiry in March 2005, Braidwood Station began taking a series of groundwater samples within Braidwood Station property boundaries. Some of those samples identified elevated levels of tritium in the Braidwood Station groundwater. Issue Report (IR) # 328451 documented these monitoring results in April 2005. This sampling continued over a period of eight months.
In response to an Illinois Environmental Protection Agency (IEPA) inquiry in March 2005, Braidwood Station began taking a series of groundwater samples within Braidwood Station property boundaries. Some of those samples identified elevated levels of tritium in the Braidwood Station groundwater. Issue Report (IR) # 328451 documented these monitoring results in April 2005. This sampling continued over a period of eight months.
In response to the results of these initial and follow-up monitoring samples, an Issues Management Team was formed on November 30, 2005 in accordance with Exelon procedure OP-AA-106-101-1002. Additional sampling resulted in elevated tritium levels being identified in groundwater in the vicinity of Circulating Water (CW)
In response to the results of these initial and follow-up monitoring samples, an Issues Management Team was formed on November 30, 2005 in accordance with Exelon procedure OP-AA-106-101-1002. Additional sampling resulted in elevated tritium levels being identified in groundwater in the vicinity of Circulating Water (CW)
Blowdown (B/D) system Vacuum Breakers (VB) #2 and CW B/D VB #3, which had experienced large volume leaks in 1998 [(VB 3) Problem Identification Form (PIF) #
Blowdown (B/D) system Vacuum Breakers (VB) #2 and CW B/D VB #3, which had experienced large volume leaks in 1998 [(VB 3) Problem Identification Form (PIF) #
Al 998-04324] and in 2000 [(VB 2) IR # 38237].
Al 998-04324] and in 2000 [(VB 2) I R # 38237].
On 30 November 2005, the Issues Management Team (IMT) initiated IR# 428868 reporting that elevated levels of tritium had been detected in onsite groundwater sampling wells and triggering this root cause investigation and report. Subsequent sampling identified elevated tritium levels outside Braidwood Station property boundaries.
On 30 November 2005, the Issues Management Team (IMT) initiated IR# 428868 reporting that elevated levels of tritium had been detected in onsite groundwater sampling wells and triggering this root cause investigation and report. Subsequent sampling identified elevated tritium levels outside Braidwood Station property boundaries.
On 16 December 2005, the Illinois Environmental Protection Agency (IEPA) issued Violation Notice W-2005-00537 to Exelon Generation - Braidwood Station, alleging Impairment of Resource Groundwater.
On 16 December 2005, the Illinois Environmental Protection Agency (IEPA) issued Violation Notice W-2005-00537 to Exelon Generation - Braidwood Station, alleging Impairment of Resource Groundwater.
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== Description:==
== Description:==
Braidwood Station identified elevated levels of tritium in the groundwater that exceed Illinois EPA regulations (Attachment 10). Due to the extended period of time and the number of events covered in this root cause investigation, the timeline became very complex. For clarity, the Event Description has been organized as follows:
Braidwood Station identified elevated levels of tritium in the groundwater that exceed Illinois EPA regulations (Attachment 10). Due to the extended period of time and the number of events covered in this root cause investigation, the timeline became very complex. For clarity, the Event Description has been organized as follows:
The Events and Causal Factors (E&CF) Chart has been placed in Attachment 4.
The Events and Causal Factors (E&CF) Chart has been placed in Attachment 4.
Line 67: Line 85:
Page 2 of 3 and page 3 of 3 depict barrier analysis of the events on VB-2 and VB-3.
Page 2 of 3 and page 3 of 3 depict barrier analysis of the events on VB-2 and VB-3.
Displayed in this event description section are:
Displayed in this event description section are:
: a. Table 1, Circulating Water (CW) Blowdown (B/D) Leak Table, which details the leaks that have been identified during this investigation.
: a.
: b. Event timeline summary with events that led up to this Root Cause Investigation.
Table 1, Circulating Water (CW) Blowdown (B/D) Leak Table, which details the leaks that have been identified during this investigation.
: 1. Attachment 12, CW B/D VB-2 and VB-3 detailed timelines.
: b.
: a.       Leaks that are within the scope of this investiqation The elevated levels of tritium have been determined to have originated from historical spills from the CW B/D system. Since 1996, 17 CW B/D vacuum breaker leaks were noted in the Braidwood Corrective Action Database and work control database. The following table is a summary of leaks identified from records, including the station's response.
Event timeline summary with events that led up to this Root Cause Investigation.
: 1. 2, CW B/D VB-2 and VB-3 detailed timelines.
: a.
Leaks that are within the scope of this investiqation The elevated levels of tritium have been determined to have originated from historical spills from the CW B/D system. Since 1996, 17 CW B/D vacuum breaker leaks were noted in the Braidwood Corrective Action Database and work control database.
The following table is a summary of leaks identified from records, including the station's response.
This team did not locate any computerized records of the Work Orders or Problem Identification Forms (PIFs) prior to approximately 1996. As such, the quantification of and response to these events had to be recreated from historical documents and interviews of involved personnel. Two means of identifying the impact of potential leaks from initial plant operation in 1988 to 1996 were considered. The first was to pull microfiche records for review and the second was to perform direct characterization of the conditions in the vicinity of all of the Circulating Water (CW)
This team did not locate any computerized records of the Work Orders or Problem Identification Forms (PIFs) prior to approximately 1996. As such, the quantification of and response to these events had to be recreated from historical documents and interviews of involved personnel. Two means of identifying the impact of potential leaks from initial plant operation in 1988 to 1996 were considered. The first was to pull microfiche records for review and the second was to perform direct characterization of the conditions in the vicinity of all of the Circulating Water (CW)
Blowdown (B/D) Vacuum Breakers (VBs).
Blowdown (B/D) Vacuum Breakers (VBs).
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===RESPONSE===
===RESPONSE===
PIF/   Immediate Particulate Tritium             10 CFR
PIF/
#  Date       Event       Leak Size   WR     CRAIR       Action     Sample         Sample       50.75(g)           Resolution l 11/27/96 VB-1         -250,000       WO,   'rocess had Requested No 1996           No 1996       No 1996     06/19/97 1" pipe to air leak     gals       96111970 personnel     repair., documents documents documents             release valve broke.
Immediate Particulate Tritium 10 CFR Date Event Leak Size WR CRAIR Action Sample Sample 50.75(g)
decide                   found.         found.       found. Tritium plume was WR or                     Will be       Tritium     Will be     identified around VB-I PIP. So,Reeito oPIF, WR                 addressed     plume was addressed       in 2006. Remediation only.                 under ATI# identified in under ATI#       being addressed under 435383     2006. Will     435383     IR# 435383.
Resolution l
11/27/96 VB-1  
-250,000 WO,  
'rocess had Requested No 1996 No 1996 No 1996 06/19/97 1" pipe to air leak gals 96111970 personnel repair.,
documents documents documents release valve broke.
decide found.
found.
found.
Tritium plume was WR or Will be Tritium Will be identified around VB-I PIP. So,Reeito oPIF, WR addressed plume was addressed in 2006. Remediation only.
under ATI# identified in under ATI# being addressed under 435383 2006. Will 435383 IR# 435383.
be addressed under ATI#
be addressed under ATI#
_435383 2   1/5/98 VB-2 leak Small leak. WR# 1rocess had Requested No 1998               No 1998       No 1998     11/08/00 replaced the 98000682 personnel     repair     documents documents       documents     float, replaced vacuum decide                   found.         found.       found. breaker and isolation WR or                     Will be       Tritium     Will be     valve. Tritium plume PIF. So,                 addressed     plume was     addressed   was identified around o l WR                   under ATI# identified in   under ATI#   VB-2 in 2005.
_435383 2
only.                   435383       2005. Will     435383     Remediation being be addressed               addressed under IR#
1/5/98 VB-2 leak Small leak.
under ATI#                 435383.
WR#
435383 3 12/4/98 VB-3         Caused         WO     A1998-       Isolated     04/26/01     No 1998     07/25/01     05/20/02 1" pipe to the leak - seat flooding. - 98127749 04324       air release       Soil     documents   evaluation   air release valve broke 3M gals                         valve until Particulate       found.     detected   due to corrosion. Guide
1rocess had Requested No 1998 No 1998 No 1998 11/08/00 replaced the 98000682 personnel repair documents documents documents float, replaced vacuum decide found.
* parts   radioactivity   Tritium   particulate   post sheared weld off could be       above     plume was   radioactivity, float. Entire vacuum received, background. identified in                   breaker replaced (July This                   2005. Will                 2001). Tritium plume stopped                 be addressed               was identified around this                 under ATI#                 VB-3 in 2005.
found.
leakage.                     435383                   Remediation being addressed under IR#
found.
breaker and isolation WR or Will be Tritium Will be valve. Tritium plume PIF. So, addressed plume was addressed was identified around o l WR under ATI# identified in under ATI# VB-2 in 2005.
only.
435383 2005. Will 435383 Remediation being be addressed addressed under IR#
under ATI#
435383.
435383 3
12/4/98 VB-3 Caused WO A1998-Isolated 04/26/01 No 1998 07/25/01 05/20/02 1" pipe to the leak - seat flooding. -
98127749 04324 air release Soil documents evaluation air release valve broke 3M gals valve until Particulate found.
detected due to corrosion. Guide
* parts radioactivity Tritium particulate post sheared weld off could be above plume was radioactivity, float. Entire vacuum received, background. identified in breaker replaced (July This 2005. Will 2001). Tritium plume stopped be addressed was identified around this under ATI#
VB-3 in 2005.
leakage.
435383 Remediation being addressed under IR#
_435383.
_435383.
4 11/6/00     VB-2     Caused       WO     A2000-     Replaced   Particulate       Tritium       Yes.       11/06/00 Float broke on leak-   flooding. - 98003276 04281       vacuum     radioactivity   plume was Sampling         vacuum breaker. Tritium seat   3M gals               Root     breaker     above           identified   detected   plume was identified Cause                 background. around VB-2 particulate       around VB-2 in 2005.
4 11/6/00 VB-2 Caused WO A2000-Replaced Particulate Tritium Yes.
38237                                 in 2005. radioactivity. Remediation being Will be                 addressed under IR#
11/06/00 Float broke on leak-flooding. -
addressed                 435383.
98003276 04281 vacuum radioactivity plume was Sampling vacuum breaker. Tritium seat 3M gals Root breaker above identified detected plume was identified Cause background. around VB-2 particulate around VB-2 in 2005.
38237 in 2005.
radioactivity. Remediation being Will be addressed under IR#
addressed 435383.
under ATI#
under ATI#
435383 5 11/10/00 VB-6         Small leak   WO       None. Requested No 2000               No 2000       No 2000           10/17/05 Valve leak                 99231846 IR should repair. documents documents documents                   assembly replaced. 2006 have been                   found.         found,       found.       remediation sampling seat                           written.                 Will be         2006       Will be     showed no tritium in the addressed       samples     addressed       groundwater at this under ATI# show no         under ATI#             location.
435383 5
435383 tritium in the       435383 groundwater_
11/10/00 VB-6 Small leak WO None.
Requested No 2000 No 2000 No 2000 10/17/05 Valve leak 99231846 IR should repair.
documents documents documents assembly replaced. 2006 have been found.
: found, found.
remediation sampling seat written.
Will be 2006 Will be showed no tritium in the addressed samples addressed groundwater at this under ATI#
show no under ATI#
location.
435383 tritium in the 435383 groundwater_
7
7


===RESPONSE===
===RESPONSE===
PIF/   Immediate Particulate Tritium           10 CFR                       -
PIF/
#  Date       Event     Leak Size   WR CR/IR         Action   Sample         Sample     50.75(g)         Resolution 6 11/20/00   VB-1     Vacuum         WO     None. Rebuilt     11/20/00       Tritium       Yes. 11/21/00 Rebuilt valve leak   breaker     99233404   IR       valve,   samples       sampling     Sampling internals. Tritium lifting.             should               reported           was     reported plume was identified have               negative for performed negative for     around VB-1 in 2006.
Immediate Particulate Tritium 10 CFR Date Event Leak Size WR CR/IR Action Sample Sample 50.75(g)
been               detectable no detectable detectable   Remediation being written.           radioactivity, activity. radioactivity   addressed under IR#
Resolution 6
1_                                       435383.
11/20/00 VB-1 Vacuum WO None.
7  6/18/01    VB-3    1/2 GPH leak    WO 4,2001- Sampled          No 2001        Tritium    No 2001  05/20/02 Rebuilt leak  from main 98127749 01806      water,    documents plume was documents          valve. Tritium plume vacuum                                      found.      identified    found. was identified around breaker.                                    Will be around VB-3 Will be          VB-3 in 2005.
Rebuilt 11/20/00 Tritium Yes.
addressed in 2005. Will addressed      Remediation being under ATI# be addressed under ATI#      addressed under IR#
11/21/00 Rebuilt valve leak breaker 99233404 IR
435383      under ATI#      435383  435383.
: valve, samples sampling Sampling internals. Tritium lifting.
should reported was reported plume was identified have negative for performed negative for around VB-1 in 2006.
been detectable no detectable detectable Remediation being written.
radioactivity, activity.
radioactivity addressed under IR#
1_
435383.
435383.
8 6/18/01   VB-9     Water in     N/A   A2001- Sampled Negative for No 2001               No 2001   No active leak.
7 6/18/01 VB-3 1/2 GPH leak WO 4,2001-Sampled No 2001 Tritium No 2001 05/20/02 Rebuilt leak from main 98127749 01806
vault.               01806   water,     detectable documents documents         Attributed to particulate     found. No     found. groundwater, 2006 adioactivity. tritium in         2006   remediation sampling groundwater remediation   showed no tritium in at this   sampling the groundwater at this location   showed no location.
: water, documents plume was documents valve. Tritium plume vacuum found.
reported in     tritium.
identified found.
was identified around breaker.
Will be around VB-3 Will be VB-3 in 2005.
addressed in 2005. Will addressed Remediation being under ATI# be addressed under ATI# addressed under IR#
435383 under ATI#
435383 435383.
435383.
8 6/18/01 VB-9 Water in N/A A2001-Sampled Negative for No 2001 No 2001 No active leak.
vault.
01806
: water, detectable documents documents Attributed to particulate found. No found.
groundwater, 2006 adioactivity.
tritium in 2006 remediation sampling groundwater remediation showed no tritium in at this sampling the groundwater at this location showed no location.
reported in tritium.
2006.
2006.
9 6/18/01   VB-10     Water in     N/A   A2001- Sampled Negative for No 2001               No 2001   No active leak.
9 6/18/01 VB-10 Water in N/A A2001-Sampled Negative for No 2001 No 2001 No active leak.
vault               01806     water,     detectable documents documents         Attributed to particulate     found. No       found, groundwater. 2006 radioactivity. tritium in       Will be remediation sampling groundwater addressed     showed no tritium in at this under ATI# the groundwater at this location in     435383   location.
vault 01806
: water, detectable documents documents Attributed to particulate found. No
: found, groundwater. 2006 radioactivity.
tritium in Will be remediation sampling groundwater addressed showed no tritium in at this under ATI# the groundwater at this location in 435383 location.
2006.
2006.
10 6/18/01   VB-11     Water in     N/A A2001- Sampled           No 2001       No 2001     No 2001       No active leak.
10 6/18/01 VB-11 Water in N/A A2001-Sampled No 2001 No 2001 No 2001 No active leak.
vault               01806     water. documents documents documents                 Attributed to found,     found. No       found. groundwater. 2006 Will be       tritium in   Will be   remediation sampling addressed groundwater addressed         showed no tritium in under ATI#       in 2006. under ATI#   the groundwater at this 435383                       435383           location.
vault 01806 water.
11   5/4/02   VB-3     Seepage       WO     106767 Requested       Sample     Per IR, RP     No 2002   05/20/02 replaced air leak - vent             0440231           repair. showed           was   documents   elease valve. Tritium above     sampling. No found.       plume was identified background documents           Will be   round VB-3 in 2005.
documents documents documents Attributed to
particulate found. Will addressed         Remediation being activity. Will be addressed under ATI#   addressed under IR#
: found, found. No found.
be addressed under ATI#         435383         435383.
groundwater. 2006 Will be tritium in Will be remediation sampling addressed groundwater addressed showed no tritium in under ATI#
under ATI#       435383 435383 8
in 2006.
under ATI# the groundwater at this 435383 435383 location.
11 5/4/02 VB-3 Seepage WO 106767 Requested Sample Per IR, RP No 2002 05/20/02 replaced air leak - vent 0440231 repair.
showed was documents elease valve. Tritium above sampling. No found.
plume was identified background documents Will be round VB-3 in 2005.
particulate found. Will addressed Remediation being activity. Will be addressed under ATI# addressed under IR#
be addressed under ATI#
435383 435383.
under ATI#
435383 435383 8


===RESPONSE===
===RESPONSE===
PIF/ Immediate Particulate     Tritium       10 CFR
PIF/
#  Date   Event   Leak Size   WR CRJIR       Action     Sample       Sample       50.75(g)       Resolution 12 8/20/03 VB-4   1 gpm to       WO     172376 None         Sample       No 2003       No 2003   9-9-03 replaced seat seat vault, no   99243232                     analysis   documents   documents     ring/float and top flooding                                 detected no     found.       found,           gasket.
Immediate Particulate Tritium 10 CFR Date Event Leak Size WR CRJIR Action Sample Sample 50.75(g)
particulate     Tritium     Willbe radioactivity plume was     addressed 8/27/03                             173204 Stopped                 identified in under ATI# Tritium plume was mod                   2006. Will 43538310. identified around VB-testing.               be addressed                   4 in 2006.
Resolution 12 8/20/03 VB-4 1 gpm to WO 172376 None Sample No 2003 No 2003 9-9-03 replaced seat seat vault, no 99243232 analysis documents documents ring/float and top flooding detected no found.
under ATI#                 Remediation being 435383                 addressed under IR#
: found, gasket.
particulate Tritium Willbe radioactivity plume was addressed 8/27/03 173204 Stopped identified in under ATI#
Tritium plume was mod 2006. Will 43538310. identified around VB-testing.
be addressed 4 in 2006.
under ATI#
Remediation being 435383 addressed under IR#
435383.
435383.
13 9/11/03 VB-4   20-40         WO     175241 Secured       No 2003     No 2003       No 2003     10/22/03 No work seat drops/min   99243232       booster     documents     documents documents         performed. Leak pumps.         found.       found.       found. determined to be from Will be       Tritium     Will be operating the system at addressed   plume was addressed       low flow. Tritium under ATI#   identified in under ATI# plume was identified 435383     2006. Will     435383   around VB-4 in 2006.
13 9/11/03 VB-4 20-40 WO 175241 Secured No 2003 No 2003 No 2003 10/22/03 No work seat drops/min 99243232 booster documents documents documents performed. Leak pumps.
be addressed                 Remediation being under ATI#                 addressed under IR#
found.
435383                       435383.
found.
14 11/18/04 VB-8 Popping /       WO 274328     Isolated     No 2004       No 2004       No 2004     10/18/05 replaced leaking,       0757898       Vacuum     documents     documents     documents valve assembly. 2006 small leak                   breaker       found.       found.       found. remediation sampling within pit                                                                       showed no tritium in the groundwater at this location.
found.
15 5/19/05 VB-I 20 drop per     WO 336401     Isolated     No 2005         Yes.       Will be   12/18/05 replaced the minute leak )0744194         valve and   documents     Sampling     addressed     vacuum breaker from the air and WR           requested     found,         was     under ATI#   assembly. Tritium release       D0178930         repair.                 performed. 435383   plume was identified valve.                                                   Tritium               around VB- I in 2006.
determined to be from Will be Tritium Will be operating the system at addressed plume was addressed low flow. Tritium under ATI# identified in under ATI# plume was identified 435383 2006. Will 435383 around VB-4 in 2006.
plume was               Being addressed under identified in                 IR# 435383.
be addressed Remediation being under ATI#
addressed under IR#
435383 435383.
14 11/18/04 VB-8 Popping /
WO 274328 Isolated No 2004 No 2004 No 2004 10/18/05 replaced
: leaking, 0757898 Vacuum documents documents documents valve assembly. 2006 small leak breaker found.
found.
found.
remediation sampling within pit showed no tritium in the groundwater at this location.
15 5/19/05 VB-I 20 drop per WO 336401 Isolated No 2005 Yes.
Will be 12/18/05 replaced the minute leak )0744194 valve and documents Sampling addressed vacuum breaker from the air and WR requested
: found, was under ATI#
assembly. Tritium release D0178930 repair.
performed.
435383 plume was identified valve.
Tritium around VB-I in 2006.
plume was Being addressed under identified in IR# 435383.
2006. Will be addressed under ATI#
2006. Will be addressed under ATI#
435383 16 5/24/05 VB-6 Seepage         WO     338111 Isolated   No 2005         Per IR,     Will be   10/19/05 rebuilt main seat from float/ 00820879         leaking   documents       sampling     addressed valve and replaced air seat area                     vacuum       found,           was     under ATI# release valve. 2006 with one                     breaker.                 performed. 435383   remediation sampling foot of water                                                                     showed no tritium in in pit.                                                                         the groundwater at this l6cation.
435383 16 5/24/05 VB-6 Seepage WO 338111 Isolated No 2005 Per IR, Will be 10/19/05 rebuilt main seat from float/
00820879 leaking documents sampling addressed valve and replaced air seat area vacuum
: found, was under ATI#
release valve. 2006 with one breaker.
performed.
435383 remediation sampling foot of water showed no tritium in in pit.
the groundwater at this l6cation.
9
9


===RESPONSE===
===RESPONSE===
PIF/ Inunediate Particulate   Tritium     10 CFR
PIF/
#  Date       Event       Leak Size   WR CR/IR     Action     Sample       Sample       50.75(g)     Resolution 17 1/16/06   VB-7     Bushing       WO 442540     Reduce       Sample           No       Will be   Pending EACE in failure. Not 0883925     B/D. Take     analysis   detectable addressed progress. Tritium plume significant..               samples. detected no tritium in       under was identified around Evaluated   particulate surface water ATI#       VB-7 in 2006, but was for   radioactivity from this       435383     due to historical regulatory               leak. Prior to           leakage. Remediation complianc                   this leak,           being addressed under e, isolated             tritium above                 IR# 435383.
Inunediate Particulate Tritium 10 CFR Date Event Leak Size WR CR/IR Action Sample Sample 50.75(g)
valve and               background wrote WR                     & below EPA drinking water limit identified in 2006 in wells used to characterize conditions near this vacuum breaker.
Resolution 17 1/16/06 VB-7 Bushing WO 442540 Reduce Sample No Will be Pending EACE in failure. Not 0883925 B/D. Take analysis detectable addressed progress. Tritium plume significant..
Responses varied from a request for normally scheduled repairs to an immediate remediation effort. The 2000 response effectively remediated the surface spill area, but did not effectively characterize the extent of condition to allow for full remediation due to weak management review and oversight of spill response activities (Root Cause 4). A contributing cause common to many of the documented events is the lack of questioning attitude and oversight by Braidwood Senior Management to the radiological implications of blowdown spills. Issue ownership and follow through were lacking in all levels of management. Corrective actions 2 and 3 address training for all levels of management.
samples.
detected no tritium in under was identified around Evaluated particulate surface water ATI#
VB-7 in 2006, but was for radioactivity from this 435383 due to historical regulatory leak. Prior to leakage. Remediation complianc this leak, being addressed under e, isolated tritium above IR# 435383.
valve and background wrote WR  
& below EPA drinking water limit identified in 2006 in wells used to characterize conditions near this vacuum breaker.
Responses varied from a request for normally scheduled repairs to an immediate remediation effort. The 2000 response effectively remediated the surface spill area, but did not effectively characterize the extent of condition to allow for full remediation due to weak management review and oversight of spill response activities (Root Cause 4).
A contributing cause common to many of the documented events is the lack of questioning attitude and oversight by Braidwood Senior Management to the radiological implications of blowdown spills. Issue ownership and follow through were lacking in all levels of management. Corrective actions 2 and 3 address training for all levels of management.
The tritium remediation plan will be tracked to completion under IR# 435383 and CAPR 2. The Braidwood Tritium Remediation Team has performed tritium characterization for the Circulating Water (CW) Blowdown (B/D) Vacuum Breakers (VBs) and performed integrity tests of the blowdown line. As of January 31, 2006, CW B/D piping acoustic testing determined that no leak above 1.0 gpm existed (minimum detectable level of testing equipment). The characterization of tritium levels in the vicinity of the vacuum breakers is described in Table 1. The station secured radioactive releases to the blowdown line on 11/23/05 and releases will remain secured until the tritium remediation team issues the final resolution under ATI# 435383-07.
The tritium remediation plan will be tracked to completion under IR# 435383 and CAPR 2. The Braidwood Tritium Remediation Team has performed tritium characterization for the Circulating Water (CW) Blowdown (B/D) Vacuum Breakers (VBs) and performed integrity tests of the blowdown line. As of January 31, 2006, CW B/D piping acoustic testing determined that no leak above 1.0 gpm existed (minimum detectable level of testing equipment). The characterization of tritium levels in the vicinity of the vacuum breakers is described in Table 1. The station secured radioactive releases to the blowdown line on 11/23/05 and releases will remain secured until the tritium remediation team issues the final resolution under ATI# 435383-07.
10
10
: b. Event timeline with events that led up to this Root Cause Investigation October 1990 "DRAFT" Commonwealth Edison procedure, CSG-001, "General Action Plan for Response to Unmonitored Releases and Very Low Level Radioactive Spills" was developed in 1990 but not implemented. This procedure contained guidance for mitigating intrusion of low-level radioactive spills into the groundwater. The reason the procedure was not implemented could not be identified. The failure to implement this procedure was not determined to be a root cause for three reasons. First, this procedure did not provide overall integrated guidance for spill evaluation and mitigation. Second, the reason the procedure was not implemented could not be identified. Third, no corrective action to prevent recurrence could be determined.         Therefore, the lack of integrated procedural guidance to ensure proper recognition, evaluation and timely mitigation of the radiological spill events was considered a root cause (Root Cause 3) for the ineffective response to Circulating Water (CW)
: b.
Event timeline with events that led up to this Root Cause Investigation October 1990 "DRAFT" Commonwealth Edison procedure, CSG-001, "General Action Plan for Response to Unmonitored Releases and Very Low Level Radioactive Spills" was developed in 1990 but not implemented. This procedure contained guidance for mitigating intrusion of low-level radioactive spills into the groundwater. The reason the procedure was not implemented could not be identified.
The failure to implement this procedure was not determined to be a root cause for three reasons. First, this procedure did not provide overall integrated guidance for spill evaluation and mitigation. Second, the reason the procedure was not implemented could not be identified. Third, no corrective action to prevent recurrence could be determined.
Therefore, the lack of integrated procedural guidance to ensure proper recognition, evaluation and timely mitigation of the radiological spill events was considered a root cause (Root Cause 3) for the ineffective response to Circulating Water (CW)
Blowdown (B/D) Vacuum Breaker (VB) leaks (Causal Factor 3, Root Cause 3).
Blowdown (B/D) Vacuum Breaker (VB) leaks (Causal Factor 3, Root Cause 3).
1991
1991 Illinois regulation 35 IAC 620 enacted, which places radioactivity limits on potable resource groundwater tritium concentration. This new regulation was not integrated into Company Procedures (Causal Factor 6).
* Illinois regulation 35 IAC 620 enacted, which places radioactivity limits on potable resource groundwater tritium concentration. This new regulation was not integrated into Company Procedures (CausalFactor6).
November 26, 1996 Found 1" pipe from VB-1 to the air release valve failed. Estimated 250,000 gallons released to the ground.
November 26, 1996
In 1996, VB-1 had a leak of approximately 250,000 gallons due to an air release valve failure.
* Found 1" pipe from VB-1 to the air release valve failed. Estimated 250,000 gallons released to the ground.
The only documented response to this event was a work order (96111970) to isolate and repair the valve. The work control process (currently Exelon procedure WC-AA-106) had no guidance for prioritizing radiological leaks which could enter the groundwater. (Failed Barrier 5). In the absence of any other recognized hazard, the current process prioritizes these work orders as a "C".
In 1996, VB-1 had a leak of approximately 250,000 gallons due to an air release valve failure. The only documented response to this event was a work order (96111970) to isolate and repair the valve. The work control process (currently Exelon procedure WC-AA-106) had no guidance for prioritizing radiological leaks which could enter the groundwater. (Failed Barrier 5). In the absence of any other recognized hazard, the current process prioritizes these work orders as a "C".
Corrective action 26 will revise WC-AA-106. No documentation could be found to indicate that any actions were taken to remediate the spill or address the potential radiological concerns. Since there was no Problem Identification Form (PIF) written to document the failure, there is no record of review of this event by Braidwood Senior Management. During this team's review of this event, the team could not find any documentation of sample analysis for radioactivity.
Corrective action 26 will revise WC-AA-106. No documentation could be found to indicate that any actions were taken to remediate the spill or address the potential radiological concerns. Since there was no Problem Identification Form (PIF) written to document the failure, there is no record of review of this event by Braidwood Senior Management. During this team's review of this event, the team could not find any documentation of sample analysis for radioactivity.
11
11


Station actions and interviews of site personnel documented that in the past, personnel did not respond to CW B/D leaks as an offsite radioactive release.
Station actions and interviews of site personnel documented that in the past, personnel did not respond to CW B/D leaks as an offsite radioactive release.
Rather, they focused on preventing. potential National Pollution Discharge Elimination System (NPDES) violations.         As long as the effluent (water) did not leave Exelon property, personnel did not always perceive a reason for concern, as NPDES requirements were considered met. The site personnel interviewed, that were present at the time of the 1996 event, were unaware of the Illinois regulation regarding groundwater tritium limits. Engineering walkdown Preventative Maintenance (PM) procedure (currently Exelon Braidwood procedure ER-BR-400-101) and Operations Department (OPS) walk down PM procedure (currently Braidwood procedure OBwOS CBW-A1) did not contain any precautions or steps for addressing CW B/D spills that potentially contain tritium (Failed Barriers 12 & 13).
Rather, they focused on preventing. potential National Pollution Discharge Elimination System (NPDES) violations.
As long as the effluent (water) did not leave Exelon property, personnel did not always perceive a reason for concern, as NPDES requirements were considered met. The site personnel interviewed, that were present at the time of the 1996 event, were unaware of the Illinois regulation regarding groundwater tritium limits.
Engineering walkdown Preventative Maintenance (PM) procedure (currently Exelon Braidwood procedure ER-BR-400-101) and Operations Department (OPS) walk down PM procedure (currently Braidwood procedure OBwOS CBW-A1) did not contain any precautions or steps for addressing CW B/D spills that potentially contain tritium (Failed Barriers 12 & 13).
Operational procedures BwOP CW-12, BwOP WX-526TI and BwOP WX-501TI had no guidance to isolate the B/D system if a known leak had occurred during a routine radiological release to the Kankakee River (Failed Barriers 15, 16, & 17).
Operational procedures BwOP CW-12, BwOP WX-526TI and BwOP WX-501TI had no guidance to isolate the B/D system if a known leak had occurred during a routine radiological release to the Kankakee River (Failed Barriers 15, 16, & 17).
No documentation was located that implied a recognition of vacuum breaker leakage impact on the requirements of the ODCM, REMP (Radiological Effluent Monitoring Program), and 10CFR50.75(g). The 1996 Annual Effluent Report did not contain an evaluation of the vacuum breaker radioactivity released and did not contain the associated evaluation of the dose to the public (IR 455079) & (CA-15).
No documentation was located that implied a recognition of vacuum breaker leakage impact on the requirements of the ODCM, REMP (Radiological Effluent Monitoring Program), and 10CFR50.75(g). The 1996 Annual Effluent Report did not contain an evaluation of the vacuum breaker radioactivity released and did not contain the associated evaluation of the dose to the public (IR 455079) & (CA-15).
NOTE:
NOTE:
As of January 2006, Elevated levels of tritium have been identified in the groundwater on Braidwood Station property close to VB-I. In one location on Braidwood property, the level of tritium was above the Illinois EPA ground water standards (20,000 picoCuries/liter). At Braidwood Station there was no site or corporate procedure for guidance on low-level radioactive spills (Failed Barriers 4 & 6). The Hazmat procedures (BwAP 750-4 & BwAP 1100-16) did not address radiological spills (Failed Barriers 1 & 2).
As of January 2006, Elevated levels of tritium have been identified in the groundwater on Braidwood Station property close to VB-I.
December, 1998
In one location on Braidwood property, the level of tritium was above the Illinois EPA ground water standards (20,000 picoCuries/liter).
* Leak from VB-3. (See Attachment 12 for more details.)
At Braidwood Station there was no site or corporate procedure for guidance on low-level radioactive spills (Failed Barriers 4 & 6). The Hazmat procedures (BwAP 750-4 & BwAP 1100-16) did not address radiological spills (Failed Barriers 1 & 2).
November 20, 2000
December, 1998 Leak from VB-3. (See Attachment 12 for more details.)
* Leak from VB-1.
November 20, 2000 Leak from VB-1.
12
12


November, 2000
November, 2000 Leak from VB-2. (See Attachment 12 for more details.)
* Leak from VB-2. (See Attachment 12 for more details.)
December 2000
December 2000
* VB-2 Root Cause Report 38237 for equipment failures was completed.
* VB-2 Root Cause Report 38237 for equipment failures was completed.
Line 173: Line 294:
Braidwood Station commenced increased investigation of environmental tritium.
Braidwood Station commenced increased investigation of environmental tritium.
January, 2005 Exelon chartered an investigation into tritium OPEX issues, with Braidwood Station providing a multi-disciplined team to support the efforts to better understand and mitigate environmental tritium issues.
January, 2005 Exelon chartered an investigation into tritium OPEX issues, with Braidwood Station providing a multi-disciplined team to support the efforts to better understand and mitigate environmental tritium issues.
March 17, 2005
March 17, 2005 On March 17th, the Illinois Environmental Protection Agency (IEPA) notified Exelon Nuclear Corporate Environmental that they were investigating tritium concentrations in wells near Braidwood Station in preparation for the Godley public hearing on Braidwood Station's NPDES permit renewal. [The Root Cause Team could not find evidence of entry of this item into the Corrective Actions Program (Missed Opportunity)].
* On March 17th, the Illinois Environmental Protection Agency (IEPA) notified Exelon Nuclear Corporate Environmental that they were investigating tritium concentrations in wells near Braidwood Station in preparation for the Godley public hearing on Braidwood Station's NPDES permit renewal. [The Root Cause Team could not find evidence of entry of this item into the Corrective Actions Program (Missed Opportunity)].
" The IEPA was working with Exelon Nuclear Corporate Environmental to understand why one of the Braidwood Radiological Effluent Monitoring Program (REMP) wells along the Kankakee River was indicating about 400 pCi/L concentration of tritium. [Since initial REMP sampling was commenced, the Braidwood REMP reports documented two wells along the Kankakee River with elevated tritium (within limits). One well returned to background levels when the well was redrilled (new casing)]
" The IEPA was working with Exelon Nuclear Corporate Environmental to understand why one of the Braidwood Radiological Effluent Monitoring Program (REMP) wells along the Kankakee River was indicating about 400 pCi/L concentration of tritium. [Since initial REMP sampling was commenced, the Braidwood REMP reports documented two wells along the Kankakee River with elevated tritium (within limits). One well returned to background levels when the well was redrilled (new casing)]
" The IEPA was investigating why shallow groundwater well #2 in Godley was reported to have tritium. (Exelon Corporate Environmental log documents that Exelon, an independent contractor, and the IEPA analyses could not confirm any tritium above background levels in any of the Godley, IL wells.)
" The IEPA was investigating why shallow groundwater well #2 in Godley was reported to have tritium. (Exelon Corporate Environmental log documents that Exelon, an independent contractor, and the IEPA analyses could not confirm any tritium above background levels in any of the Godley, IL wells.)
Line 185: Line 305:
: 3. The two monitoring wells used for the previous environmental remediation sampling on the west side of the Turbine Building.
: 3. The two monitoring wells used for the previous environmental remediation sampling on the west side of the Turbine Building.
" The IEPA was informed that Exelon installed wells to determine a groundwater gradient near the blowdown line spill at VB-2 that occurred in November 2000. These wells were installed for hydrology analysis.
" The IEPA was informed that Exelon installed wells to determine a groundwater gradient near the blowdown line spill at VB-2 that occurred in November 2000. These wells were installed for hydrology analysis.
* The IEPA requested that Exelon provide a sample of the offsite drainage ditch and samples from the four shallow monitoring wells that were installed in the area of the November, 2000 blowdown line leak.
The IEPA requested that Exelon provide a sample of the offsite drainage ditch and samples from the four shallow monitoring wells that were installed in the area of the November, 2000 blowdown line leak.
* The IEPA asked Braidwood Station to sample the shallow Godley well, which was reported to be contaminated with tritium, because the Agency would like to have a recent tritium analysis on it.
* The IEPA asked Braidwood Station to sample the shallow Godley well, which was reported to be contaminated with tritium, because the Agency would like to have a recent tritium analysis on it.
March 24, 2005 An Independent contractor sampled the following per IEPA March 23, 2005 request:
March 24, 2005 An Independent contractor sampled the following per IEPA March 23, 2005 request:
Line 196: Line 316:
: 6. The four shallow monitoring wells that were installed in the area of the November 2000 blowdown line leak 14
: 6. The four shallow monitoring wells that were installed in the area of the November 2000 blowdown line leak 14


April 1, 2005 Results (reference Braidwood Chemistry Department Sample Log) from the March 24 tritium samples taken at Braidwood Station indicated presence of tritium above background in the following locations (See Attachment 7 for Map):
April 1, 2005 Results (reference Braidwood Chemistry Department Sample Log) from the March 24 tritium samples taken at Braidwood Station indicated presence of tritium above background in the following locations (See for Map):
: 1. The cooling lake in the discharge canal - < background
: 1. The cooling lake in the discharge canal - < background
: 2. The cooling lake in the northwest corner - < background
: 2. The cooling lake in the northwest corner - < background
: 3. Sample point MW-4, near the November 2000 VB-2 leak -. above background Sample point MW-6, West side of Turbine Building - above background Additional Exelon samples
: 3. Sample point MW-4, near the November 2000 VB-2 leak -. above background Sample point MW-6, West side of Turbine Building -
above background Additional Exelon samples
: 4. The cooling lake on the east-west dike approximately halfway in the middle - < background
: 4. The cooling lake on the east-west dike approximately halfway in the middle - < background
: 5. Sample point BD-101, Braidwood drainage ditch - above background
: 5. Sample point BD-101, Braidwood drainage ditch above background
: 6. The four shallow monitoring wells that were installed in the area of the November 2000 blowdown line leak. Three were < background.
: 6. The four shallow monitoring wells that were installed in the area of the November 2000 blowdown line leak. Three were < background.
One was above background The levels identified in these samples were well below the federal standard of 20,000 picoCuries/liter (pCi/L).
One was above background The levels identified in these samples were well below the federal standard of 20,000 picoCuries/liter (pCi/L).
* Although the tritium levels were well below federal standards, Braidwood commenced detailed sampling and investigation.
* Although the tritium levels were well below federal standards, Braidwood commenced detailed sampling and investigation.
April 15, 2005 Exelon sent Godley well results and the second sample on the drainage ditch to the IEPA. Samples had been collected on April 7, 2005:
April 15, 2005 Exelon sent Godley well results and the second sample on the drainage ditch to the IEPA. Samples had been collected on April 7, 2005:
Sample Location                 Sample ID           Result BD-101 (Drainage Ditch)       BDSW-1 665           twice background Godley Rec. Center             BDWW-1666           less than background Godley Rec. Center             BDWW-1 667           less than background April 25, 2005 IR 328451 was generated to identify tritium levels above background in the Braidwood drainage ditch.
Sample Location Sample ID Result BD-101 (Drainage Ditch)
BDSW-1 665 twice background Godley Rec. Center BDWW-1666 less than background Godley Rec. Center BDWW-1 667 less than background April 25, 2005 IR 328451 was generated to identify tritium levels above background in the Braidwood drainage ditch.
15
15


May 5, 2005
May 5, 2005
* Additional samples were taken at three locations in and around the Braidwood drainage ditch in an attempt to better define the source of the tritium.
* Additional samples were taken at three locations in and around the Braidwood drainage ditch in an attempt to better define the source of the tritium.
May 9, 2005
May 9, 2005 Due to the results of the March 24, 2005 sample and confirmatory sampling of Braidwood drainage ditch, Braidwood Station expanded the sampling and investigation to focus on both surface water and groundwater sample points.
* Due to the results of the March 24, 2005 sample and confirmatory sampling of Braidwood drainage ditch, Braidwood Station expanded the sampling and investigation to focus on both surface water and groundwater sample points.
May 10, 2005 Five shallow groundwater wells (GW-1, GW-2, TW-20, OW-32 and OW-
May 10, 2005 Five shallow groundwater wells (GW-1, GW-2, TW-20, OW-32 and OW-
: 33) were sampled (See Attachment 7 for Map). These five wells are located onsite and are positioned between the Braidwood drainage ditch and the Village of Godley. These samples were to provide more detailed information to samples previously collected on May 5. No tritium was detected above background concentrations in any of these five samples.
: 33) were sampled (See Attachment 7 for Map).
These five wells are located onsite and are positioned between the Braidwood drainage ditch and the Village of Godley. These samples were to provide more detailed information to samples previously collected on May 5.
No tritium was detected above background concentrations in any of these five samples.
May 17, 2005
May 17, 2005
" A conference call was held with IEPA to exchange recent sample results and to discuss sampling in the Braidwood Station onsite wells (GW-1, GW-2, TW-20, OW-32 and OW-33) (See Attachment 7 for Map). The IEPA reported all tritium samples as less than background, which corroborated the site's results.
" A conference call was held with IEPA to exchange recent sample results and to discuss sampling in the Braidwood Station onsite wells (GW-1, GW-2, TW-20, OW-32 and OW-33) (See Attachment 7 for Map).
" The IEPA stated that they would acquire four samples from residents in Godley who live along side the drainage ditch and would analyze the samples for tritium. The Agency would provide duplicate samples for Exelon tritium analyses and would notify us when the sampling was scheduled.
The IEPA reported all tritium samples as less than background, which corroborated the site's results.
" The IEPA stated that they would acquire four samples from residents in Godley who live along side the drainage ditch and would analyze the samples for tritium.
The Agency would provide duplicate samples for Exelon tritium analyses and would notify us when the sampling was scheduled.
May 18, 2005 A 20 drop per minute leak from the pilot valve of vacuum breaker #1 (VB-
May 18, 2005 A 20 drop per minute leak from the pilot valve of vacuum breaker #1 (VB-
: 1) was identified during a walk down by Braidwood Engineering. A sample was acquired and sent for analysis. (See Attachment 7 for Map) 16
: 1) was identified during a walk down by Braidwood Engineering.
A sample was acquired and sent for analysis. (See Attachment 7 for Map) 16


May 19, 2005 The tritium concentration in the sample of the leak catch tray at the VB-1 leak was above the IEPA standard for groundwater. (There was no evidence of leakage outside of the catch tray).
May 19, 2005 The tritium concentration in the sample of the leak catch tray at the VB-1 leak was above the IEPA standard for groundwater. (There was no evidence of leakage outside of the catch tray).
Line 225: Line 351:
" Braidwood Station briefed the Nuclear Regulatory Commission (NRC)
" Braidwood Station briefed the Nuclear Regulatory Commission (NRC)
Inspector from the Region III Office on the drainage ditch tritium results.
Inspector from the Region III Office on the drainage ditch tritium results.
An overview of the sampling performed to date, along with the results of the sampling and a copy of the collated sample results, were presented to the NRC as part of the routine Offsite Dose Calculation Manual (ODCM)/Radiological Environmental           Monitoring   Program (REMP) inspection.
An overview of the sampling performed to date, along with the results of the sampling and a copy of the collated sample results, were presented to the NRC as part of the routine Offsite Dose Calculation Manual (ODCM)/Radiological Environmental Monitoring Program (REMP) inspection.
* Tritium analyses performed on five water samples collected at Braidwood Station on May 20, 2005 were less than background except for the VB-3 Pit tritium concentration which was above background (See Attachment 12 for VB-3 timeline).
* Tritium analyses performed on five water samples collected at Braidwood Station on May 20, 2005 were less than background except for the VB-3 Pit tritium concentration which was above background (See Attachment 12 for VB-3 timeline).
June 14, 2005
June 14, 2005 Exelon and IEPA acquired four samples from the Godley wells per the May 17 request.
* Exelon and IEPA acquired four samples from the Godley wells per the May 17 request.
June 20, 2005
June 20, 2005
* As part of the investigation to determine the source of tritium, the station received the independent contractor proposal to install monitoring wells to focus on:
* As part of the investigation to determine the source of tritium, the station received the independent contractor proposal to install monitoring wells to focus on:
o   Examining the groundwater impact in the area of VB-1 located south of the switchyard o   Determining the movement and direction of groundwater and its relationship to surface water on both the east and north side of the Braidwood Station property June 28, 2005
o Examining the groundwater impact in the area of VB-1 located south of the switchyard o
Determining the movement and direction of groundwater and its relationship to surface water on both the east and north side of the Braidwood Station property June 28, 2005
* The results of the four Godley well samples taken on June 14, showed no tritium levels above background.
* The results of the four Godley well samples taken on June 14, showed no tritium levels above background.
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July 22, 2005 Exelon installed monitoring wells to investigate potential leakage around VB-1 and VB-3 that may be contributing to leakage in the Braidwood drainage ditch: (See Attachment 7 for Map) o   Sample   point MW-1 06, near the fresh water holding-pond o   Sample   point MW-1 07, SE corner of the switchyard near VB-1 o   Sample   point MW-108, east of VB-1 near the CW B/D line o   Sample   point MW-1 09, east of the switchyard near the Braidwood ditch September 23, 2005 Exelon pursued additional resources to expand the scope of the tritium investigative activities to more clearly define the source of the tritium, which had been discovered in the drainage ditch. This information was communicated by phone to the IEPA.
July 22, 2005 Exelon installed monitoring wells to investigate potential leakage around VB-1 and VB-3 that may be contributing to leakage in the Braidwood drainage ditch: (See Attachment 7 for Map) o Sample point MW-1 06, near the fresh water holding-pond o Sample point MW-1 07, SE corner of the switchyard near VB-1 o Sample point MW-108, east of VB-1 near the CW B/D line o Sample point MW-1 09, east of the switchyard near the Braidwood ditch September 23, 2005 Exelon pursued additional resources to expand the scope of the tritium investigative activities to more clearly define the source of the tritium, which had been discovered in the drainage ditch. This information was communicated by phone to the IEPA.
October 2005
October 2005 Exelon installed monitoring wells as part of an expanded scope of the tritium investigation: (See Attachment 7 for Map) o Sample point MW-110, north of the meteorological tower o Sample points MW-111, MW-112, and MW-113, north property line near Smiley Road October 25, 2005 Initiated IR# 390133 to address difference between historical annual liquid discharge curie content and the UFSAR description. Investigation of this difference determined that no change was required.
* Exelon installed monitoring wells as part of an expanded scope of the tritium investigation: (See Attachment 7 for Map) o   Sample point MW-110, north of the meteorological tower o   Sample points MW-111, MW-112, and MW-113, north property line near Smiley Road October 25, 2005 Initiated IR# 390133 to address difference between historical annual liquid discharge curie content and the UFSAR description. Investigation of this difference determined that no change was required.
November 9, 2005 Two of the four groundwater samples collected on October 19 and October 20, 2005 from the new monitoring wells exceeded the Offsite Dose Calculation Manual (ODCM) Lower Limit of Detection of 2000 pCi/L.
November 9, 2005 Two of the four groundwater samples collected on October 19 and October 20, 2005 from the new monitoring wells exceeded the Offsite Dose Calculation Manual (ODCM) Lower Limit of Detection of 2000 pCi/L.
Upon this indication, Braidwood Station assembled an Exelon Issues Management Team (OP-AA-1 06-101-1002) to evaluate the tritium issue.
Upon this indication, Braidwood Station assembled an Exelon Issues Management Team (OP-AA-1 06-101-1002) to evaluate the tritium issue.
Line 247: Line 372:
* Braidwood Station terminated the use of the Circulating Water (CW)
* Braidwood Station terminated the use of the Circulating Water (CW)
Blowdown (B/D) system for radioactive liquid releases pending resolution of this root cause investigation and appropriate corrective actions.
Blowdown (B/D) system for radioactive liquid releases pending resolution of this root cause investigation and appropriate corrective actions.
November 30, 2005
November 30, 2005 Issues Management Team was formed to address tritium issues.
* Issues Management Team was formed to address tritium issues.
December 2, 2005 Emergency Notification System (ENS) notification made to the NRC due to the notification of other -government agencies' (IEPA) and a press release.
December 2, 2005
* Emergency Notification System (ENS) notification made to the NRC due to the notification of other -government agencies' (IEPA) and a press release.
January 15, 2006 As this RCR was being finalized, a leak occurred on VB-7 due to failure of an internal guide and was documented on IR# 00442540. (See analysis section of how this issue is addressed) (See Attachment 7 for Map)
January 15, 2006 As this RCR was being finalized, a leak occurred on VB-7 due to failure of an internal guide and was documented on IR# 00442540. (See analysis section of how this issue is addressed) (See Attachment 7 for Map)
* The standing water posed no radiological concern because CW B/D radiological releases had been held in abeyance since November 23, 2005.
* The standing water posed no radiological concern because CW B/D radiological releases had been held in abeyance since November 23, 2005.
* The standing water in the vicinity of VB-7 was sampled for gamma radioactivity and tritium (no radioactivity detected) and evaluated for NPDES compliance. An environmental specialist verified that the leakage did not reach runoff ditches or creeks and therefore NPDES requirements were met.
The standing water in the vicinity of VB-7 was sampled for gamma radioactivity and tritium (no radioactivity detected) and evaluated for NPDES compliance. An environmental specialist verified that the leakage did not reach runoff ditches or creeks and therefore NPDES requirements were met.
* Prior to this leak, tritium above background and below the EPA drinking water limit was identified in 2006 in wells used to characterize conditions near this vacuum breaker. The source of this tritium is likely to be leakage prior to 1996 as no record of leakage subsequent to 1996 could be located.
Prior to this leak, tritium above background and below the EPA drinking water limit was identified in 2006 in wells used to characterize conditions near this vacuum breaker. The source of this tritium is likely to be leakage prior to 1996 as no record of leakage subsequent to 1996 could be located.
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Line 269: Line 392:
Effectiveness of Braidwood Station response to radioactive leaks:
Effectiveness of Braidwood Station response to radioactive leaks:
Interviews played an integral part in the determination of this root cause due to the lack of written information that was available from the Corrective Action Program (CAP) to this Root Cause Investigation Team for the Circulating Water (CW)
Interviews played an integral part in the determination of this root cause due to the lack of written information that was available from the Corrective Action Program (CAP) to this Root Cause Investigation Team for the Circulating Water (CW)
Blowdown (B/D) events. The fact that some spills were not captured in the Corrective Action Program is indicative of weak management review and oversight of spill response activities (Root Cause 4).
Blowdown (B/D) events.
A potential root cause that was considered was that draft Commonwealth Edison procedure CSG-001, "General Action Plan For Response To Unmonitored Releases And Very Low Level Radioactivity Spills" was not implemented. This procedure contained guidance for mitigating intrusion of low-level radioactive spills into the groundwater. There was no reason found as to why the procedure was not implemented.
The fact that some spills were not captured in the Corrective Action Program is indicative of weak management review and oversight of spill response activities (Root Cause 4).
The failure to implement this procedure was not determined to be a root cause for three reasons. First, this procedure did not provide overall integrated guidance for spill evaluation and mitigation. Second, the reason the procedure was not implemented could not be identified.         Third, no corrective action to prevent recurrence could be determined.         Therefore, the lack of integrated procedural guidance to ensure proper recognition, evaluation and timely mitigation of the radiological spill events was considered a root cause (Root Cause 3) for the ineffective response to Circulating Water (CW) Blowdown (B/D) Vacuum Breaker (VB) leaks (CausalFactor3, Root Cause 3).
A potential root cause that was considered was that draft Commonwealth Edison procedure CSG-001, "General Action Plan For Response To Unmonitored Releases And Very Low Level Radioactivity Spills" was not implemented.
For example, in a number of events the station addressed the NPDES concerns but no Radiation Protection (RP) individuals were engaged to address radiological concerns. Additionally, when personnel with the requisite knowledge base were involved, the lack of a pre-engineered solution that could be executed was not available. This hampered response, as each step had to be created and reviewed before actions occurred. At the time of the 2000 spill, the final remediation steps were missed under these circumstances, as independent expert reviews/challenges did not occur.
This procedure contained guidance for mitigating intrusion of low-level radioactive spills into the groundwater.
There was no reason found as to why the procedure was not implemented.
The failure to implement this procedure was not determined to be a root cause for three reasons. First, this procedure did not provide overall integrated guidance for spill evaluation and mitigation. Second, the reason the procedure was not implemented could not be identified.
Third, no corrective action to prevent recurrence could be determined.
Therefore, the lack of integrated procedural guidance to ensure proper recognition, evaluation and timely mitigation of the radiological spill events was considered a root cause (Root Cause 3) for the ineffective response to Circulating Water (CW) Blowdown (B/D) Vacuum Breaker (VB) leaks (Causal Factor 3, Root Cause 3).
For example, in a number of events the station addressed the NPDES concerns but no Radiation Protection (RP) individuals were engaged to address radiological concerns.
Additionally, when personnel with the requisite knowledge base were involved, the lack of a pre-engineered solution that could be executed was not available. This hampered response, as each step had to be created and reviewed before actions occurred.
At the time of the 2000 spill, the final remediation steps were missed under these circumstances, as independent expert reviews/challenges did not occur.
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21


Evaluation Methods used during the investigation process for the Root Cause.
Evaluation Methods used during the investigation process for the Root Cause.
RC Tool                 Why used                           Advantages                     Disadvantages overcome Event and Causal         Utilized due to the complexity     Provide an illustration of the While time consuming, enlisted Factor Chart (Att 4)     of the issues and actions over     whole problem and               a full-time Root Cause person time.                             contributing factors,           for the skill/experience and Works very well with barrier  time large The  to create an E&CF number          Chart.
RC Tool Why used Advantages Disadvantages overcome Event and Causal Utilized due to the complexity Provide an illustration of the While time consuming, enlisted Factor Chart (Att 4) of the issues and actions over whole problem and a full-time Root Cause person time.
of events verge n a               ever, analysis, which became necessary during the           verged on a CCA. However, evaluation,                     one event was taken to represent them all and the analyses were completed utilizing that event (the 1998 event) as the template.
contributing factors, for the skill/experience and time to create an E&CF Chart.
TapRoot                 Used to assign the cause codes     Consistent approach for more   Difficult to utilize and for individual causes of the       reliable cause coding.         understand categories.
Works very well with barrier The large number of events analysis, which became verge n a
event.                                                             Technique was used in conjunction with Trending/Coding procedure and Team input/brainstorming of causes.
: ever, necessary during the verged on a CCA. However, evaluation, one event was taken to represent them all and the analyses were completed utilizing that event (the 1998 event) as the template.
Barrier Analysis (Att 2) Used extensively, as people,       Used to identify causal factors Utilized Team brainstorming to physical, and administrative       systematically, With the E&CF   assure all barriers were barriers should have prevented     chart and Cause & Effect       recognized.
TapRoot Used to assign the cause codes Consistent approach for more Difficult to utilize and for individual causes of the reliable cause coding.
the issue.                         analysis to identify process weaknesses. Supports proposed corrective actions.
understand categories.
Change Analysis         Team tried to utilize to evaluate Made for a good starting point Information contained in this (Att 5)                 changes in procedures and         in analysis of the E&CF chart, attachment was inadequate to regulations.                                                       use effectively and was therefore not utilized as an input to this root cause report.
event.
Cause and Effect         Found the "Why" Stair Case         This analysis method was key   Utilized E&CF chart and area Analysis (Att 3)         instrumental due to the large     in finding the common/root     experts in OPS, RP, Chemistry number of failed barriers,         cause used with barrier         - Environmental, and other analysis.                       stations as well as RA and Corporate to ensure entire background was understood for this complex problem.
Technique was used in conjunction with Trending/Coding procedure and Team input/brainstorming of causes.
Failure Modes and       Not Used                           Not Used                       Not Used Effects Analysis 22
Barrier Analysis (Att 2)
Used extensively, as people, Used to identify causal factors Utilized Team brainstorming to physical, and administrative systematically, With the E&CF assure all barriers were barriers should have prevented chart and Cause & Effect recognized.
the issue.
analysis to identify process weaknesses. Supports proposed corrective actions.
Change Analysis Team tried to utilize to evaluate Made for a good starting point Information contained in this (Att 5) changes in procedures and in analysis of the E&CF chart, attachment was inadequate to regulations.
use effectively and was therefore not utilized as an input to this root cause report.
Cause and Effect Found the "Why" Stair Case This analysis method was key Utilized E&CF chart and area Analysis (Att 3) instrumental due to the large in finding the common/root experts in OPS, RP, Chemistry number of failed barriers, cause used with barrier  
- Environmental, and other analysis.
stations as well as RA and Corporate to ensure entire background was understood for this complex problem.
Failure Modes and Not Used Not Used Not Used Effects Analysis 22


Evaluation:
Evaluation:
Cause (describe the cause and Po m identify whether it Problemis           a root cause or a Statement         contributing cause) Basis for Cause Determination Unplanned         Causal Factor 1,
Cause (describe the cause and Po m identify whether it Problemis a root cause or a Statement contributing cause)
* Preventive Maintenance -The preventive maintenance program in year 2000 releases to the  Root Cause 1                had no requirement to perform any kind of internal valve inspection or ground from      The root cause              operational check and no requirement to periodically replace the valves. The unauthorized      of the large                vacuum breaker valves were essentially installed as runto failure components.
Basis for Cause Determination Unplanned releases to the ground from unauthorized release paths.
release paths. volume leaks in            There were no Technical Specification requirements or NRC commitments to 1998 and 2000 is            conduct periodic maintenance. Prior to 1999, walkdowns of the blowdown documented in                system were performed annually.
Causal Factor 1, Root Cause 1 The root cause of the large volume leaks in 1998 and 2000 is documented in Root Cause Report (RCR) 38237, which determined that the Circulating Water (CW)
Root Cause Report (RCR)                In July l 999, a preventive maintenance template from STANDARD NES-G-08, 38237, which                CoinEd Performance Centered Maintenance (PCM) Templates, was adopted for determined that            application~to the vacuum breaker valves. The particular template chosen is the Circulating            specifically applicable to spring actuated safety relief valves, and contains no Water (CW)                  discussion of applicability to float type valves. The predefine task description is Blowdown                    "perform setpoint verification and seat leak check, or replace valve". The (B/D) Vacuum                periodicity was set at 10 years. The template chosen was the closest match from Breaker (VB)                all those available in the standard PCM template index.
Blowdown (B/D) Vacuum Breaker (VB)
Valves had inadequate                  . esign/Application -The barrier was challenged when system operation was D
Valves had inadequate preventative maintenance programs and inadequate design configuration.
preventative                changed without changing the design or configuration of the vacuum breaker maintenance                assemblies.
Preventive Maintenance -The preventive maintenance program in year 2000 had no requirement to perform any kind of internal valve inspection or operational check and no requirement to periodically replace the valves. The vacuum breaker valves were essentially installed as runto failure components.
programs and inadequate                  Original CW blowdown system operation provided for controlling blowdown design                      flow using valves at the river screen house, thus the system would always configuration.              remain full of water. This method of operation was abandoned within the first two years of operation due to repetitive failures of the control valves. Operation thereafter provided for controlling blowdown flow using valves located in the plant near the main condensers and when flow is secured, the blowdown line would depressurize and partially drain resulting in a potential pressure surge when flow was reinitiated. Discussion with the valve manufacturer revealed that if the valves are subjected to significant pressure surges, they should be equipped with surge protection. The current configuration had no surge protection. The reason why the system operation was changed rather than correcting the material condition of the valves at the river screen house was not pursued since that decision was historical. Similarly, the reason the change was made without considering impact on the vacuum breaker design/configuration cannot be determined.
There were no Technical Specification requirements or NRC commitments to conduct periodic maintenance. Prior to 1999, walkdowns of the blowdown system were performed annually.
In July l 999, a preventive maintenance template from STANDARD NES-G-08, CoinEd Performance Centered Maintenance (PCM) Templates, was adopted for application~to the vacuum breaker valves. The particular template chosen is specifically applicable to spring actuated safety relief valves, and contains no discussion of applicability to float type valves. The predefine task description is "perform setpoint verification and seat leak check, or replace valve". The periodicity was set at 10 years. The template chosen was the closest match from all those available in the standard PCM template index.
.Design/Application -The barrier was challenged when system operation was changed without changing the design or configuration of the vacuum breaker assemblies.
Original CW blowdown system operation provided for controlling blowdown flow using valves at the river screen house, thus the system would always remain full of water. This method of operation was abandoned within the first two years of operation due to repetitive failures of the control valves. Operation thereafter provided for controlling blowdown flow using valves located in the plant near the main condensers and when flow is secured, the blowdown line would depressurize and partially drain resulting in a potential pressure surge when flow was reinitiated. Discussion with the valve manufacturer revealed that if the valves are subjected to significant pressure surges, they should be equipped with surge protection. The current configuration had no surge protection. The reason why the system operation was changed rather than correcting the material condition of the valves at the river screen house was not pursued since that decision was historical. Similarly, the reason the change was made without considering impact on the vacuum breaker design/configuration cannot be determined.
On January 16, 2006, a leak occurred on VB-7 due to failure of an internal guide bushing and was documented on IR 00442540. EACE 442540 is performing an evaluation of this failure. The results of the EACE will be reviewed to determine if the findings in this root cause are still valid. Corrective Action 29 will track this issue.
On January 16, 2006, a leak occurred on VB-7 due to failure of an internal guide bushing and was documented on IR 00442540. EACE 442540 is performing an evaluation of this failure. The results of the EACE will be reviewed to determine if the findings in this root cause are still valid. Corrective Action 29 will track this issue.
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Cause (describe the cause and Problem     identify whether it is a root cause or a Statement   contributing cause) Basis for Cause Determination Causal Factor 2,
Cause (describe the cause and Problem identify whether it is a root cause or a Statement contributing cause)
* Although the corrective actions from the 38237 Root Cause Report were Root Cause 2               effective, the report did not address "small" spills because the need for a near The root cause             zero leakage standard was not k"own or suspected. The near zero leakage of the small               requirement was not identified in the 2000 Root Cause Report investigation due leaks, which               to a lack of technical rigor/questioning attitude. For details, refer to Attachment both preceded               12.
Basis for Cause Determination Causal Factor 2, Although the corrective actions from the 38237 Root Cause Report were Root Cause 2 effective, the report did not address "small" spills because the need for a near The root cause zero leakage standard was not k"own or suspected. The near zero leakage of the small requirement was not identified in the 2000 Root Cause Report investigation due leaks, which to a lack of technical rigor/questioning attitude. For details, refer to Attachment both preceded 12.
and succeeded the 1998 and 2000 leaks, was that the need for a near zero leakage standard was not identified, due to a lack of Technical Rigor/Questionin g Attitude.
and succeeded the 1998 and 2000 leaks, was that the need for a near zero leakage standard was not identified, due to a lack of Technical Rigor/Questionin g Attitude.
Inadequate Causal Factor 3,
Inadequate Causal Factor 3, After this root cause was identified, it was analyzed to determine if it was response to Root Cause 3:
* After this root cause was identified, it was analyzed to determine if it was response to Root Cause 3:               appropriate for this event. In other words, the team considered whether the unplanned   The first root             "why" question had been asked enough to adequately resolve the problem. The releases. cause for the               team attempted to ask "why" and there is no clear/concrete documentation to ineffective                 explain why this 1990 procedure was not implemented (Failed Barrier, FB-4).
appropriate for this event. In other words, the team considered whether the unplanned The first root "why" question had been asked enough to adequately resolve the problem. The releases.
response was a             Utilizing TapRoot analysis process, the root cause is the most basic cause (or lack of                     causes) that can be reasonably identified that management has control to correct integrated                 and when corrected, will prevent (or significantly reduce the likelihood of) the procedural                 issue recurring. In this event, Braidwood Senior Management has the ability to guidance to                 implement integrated procedural guidance to ensure thenecessary knowledge of ensure proper               local hydrology, the impact of low-level tritium leaks, and groundwater recognition,               regulations is directed to ensure consistent mitigation and remediation of future evaluation, and             events. Thus, it was concluded that the root cause statement met the criteria of timely mitigation           the TapRoot definition and it was appropriate for this event.
cause for the team attempted to ask "why" and there is no clear/concrete documentation to ineffective explain why this 1990 procedure was not implemented (Failed Barrier, FB-4).
of the                 *  (Failed Barriers FB 1 -17) (See Attachment 2) CSG-001 1990 (draft only) radiological spill         contained guidance regarding underground transport mechanism for tritium and events.                     directions to remediate this pathway.         Procedures for responding to and assessing radiological spills are either non-existent or inadequate. There was limited guidance to acknowledge 35 IAC 620 requirements or subsurface transport mechanisms to provide dose to the public. Failed barriers 1-17 address lack of integrated procedural guidance to ensure proper evaluation of the event, including knowledge of local hydrology, the impact of low-level tritium leaks, and groundwater regulations. This procedure contained instructions for mitigating intrusion of low-level radioactive spills into the groundwater. The reason the procedure was not implemented, could not be identified. Because this procedure did not provide overall integrated guidance for spill evaluation and mitigation, the failure to implement the procedure was not considered a root cause.
response was a Utilizing TapRoot analysis process, the root cause is the most basic cause (or lack of causes) that can be reasonably identified that management has control to correct integrated and when corrected, will prevent (or significantly reduce the likelihood of) the procedural issue recurring. In this event, Braidwood Senior Management has the ability to guidance to implement integrated procedural guidance to ensure thenecessary knowledge of ensure proper local hydrology, the impact of low-level tritium leaks, and groundwater recognition, regulations is directed to ensure consistent mitigation and remediation of future evaluation, and events. Thus, it was concluded that the root cause statement met the criteria of timely mitigation the TapRoot definition and it was appropriate for this event.
Therefore, the lack of integrated procedural guidance to ensure proper recognition, evaluation and timely mitigation of the radiological spill events was considered a root cause (Root Cause 3) for the ineffective response to Circulating Water (CW) Blowdown (B/D) Vacuum Breaker (VB) leaks (Causal Factor3, Root Cause 3).
of the (Failed Barriers FB 1 -17)
(See Attachment 2) CSG-001 1990 (draft only) radiological spill contained guidance regarding underground transport mechanism for tritium and events.
directions to remediate this pathway.
Procedures for responding to and assessing radiological spills are either non-existent or inadequate. There was limited guidance to acknowledge 35 IAC 620 requirements or subsurface transport mechanisms to provide dose to the public. Failed barriers 1-17 address lack of integrated procedural guidance to ensure proper evaluation of the event, including knowledge of local hydrology, the impact of low-level tritium leaks, and groundwater regulations. This procedure contained instructions for mitigating intrusion of low-level radioactive spills into the groundwater. The reason the procedure was not implemented, could not be identified. Because this procedure did not provide overall integrated guidance for spill evaluation and mitigation, the failure to implement the procedure was not considered a root cause.
Therefore, the lack of integrated procedural guidance to ensure proper recognition, evaluation and timely mitigation of the radiological spill events was considered a root cause (Root Cause 3) for the ineffective response to Circulating Water (CW) Blowdown (B/D) Vacuum Breaker (VB) leaks (Causal Factor 3, Root Cause 3).
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24


Cause     (describe the cause and Problem     identify whether it is a root cause or a Statement   contributing cause)   Basis for Cause Determination Inadequate Causal Factor 4,           "    In review of the 2000 Issues Management Team notes and other available response to Root Cause 4.                  documentation, the ineffective response from both the station and corporate unplanned  A second root                  levels appears to have been due to a lack of clear delineation of specific releases. cause for the                  responsibilities during radiological spill response and remediation efforts.
Cause (describe the cause and Problem identify whether it is a root cause or a Statement contributing cause)
ineffective                    Specifically, the interface of site and corporate Radiation Protection, Chemistry response was                    and Environmental departments are not clearly defined.
Basis for Cause Determination Inadequate response to unplanned releases.
weak                      "    Due to the cross discipline teams needed to respond /document a low level management                      radioactive leak and the lack of one procedure to integrate the response, CAPR review and                      4 will ensure all aspects are covered.
Causal Factor 4, Root Cause 4.
oversight of spill response
A second root cause for the ineffective response was weak management review and oversight of spill response activities.
* Original 2000 root cause (38237) was too narrowly focused.
In review of the 2000 Issues Management Team notes and other available documentation, the ineffective response from both the station and corporate levels appears to have been due to a lack of clear delineation of specific responsibilities during radiological spill response and remediation efforts.
activities.                "    The Issues Management Team actions had no accountability or tracking through the CAP process.
Specifically, the interface of site and corporate Radiation Protection, Chemistry and Environmental departments are not clearly defined.
* Did not properly execute issue management procedures.
Due to the cross discipline teams needed to respond /document a low level radioactive leak and the lack of one procedure to integrate the response, CAPR 4 will ensure all aspects are covered.
                                      "    Unaware of the 1991 State regulation regarding tritium limits.
Original 2000 root cause (38237) was too narrowly focused.
The Issues Management Team actions had no accountability or tracking through the CAP process.
Did not properly execute issue management procedures.
Unaware of the 1991 State regulation regarding tritium limits.
A Senior Corporate Manager was chosen to assemble and direct the radiological remediation team. Four Corporate procedures which direct issues management were properly entered to identify, evaluate, remediate and communicate the radiological concerns. The four procedures include:
A Senior Corporate Manager was chosen to assemble and direct the radiological remediation team. Four Corporate procedures which direct issues management were properly entered to identify, evaluate, remediate and communicate the radiological concerns. The four procedures include:
* NSP-RP-6101, "10 CFR 50.75(g)(1) Documentation Requirements"
NSP-RP-6101, "10 CFR 50.75(g)(1) Documentation Requirements" CWPI-NSP-I-I, "CAP Process Manual of Common Work Practice Instructions
* CWPI-NSP- I-I, "CAP Process Manual of Common Work PracticeInstructions
- Instruction on Event Response Guidelines" OP-AA-101-501, "NGG Significant Event Reporting" OP-AA-101-503, "NGG Issues Management".
                                                - Instruction on Event Response Guidelines"
* OP-AA-101-501, "NGG Significant Event Reporting"
* OP-AA- 101-503, "NGG Issues Management".
However, no historical documentation could be located. to demonstrate that the procedures (other than NSP-RP-6101) were fully executed. This indicates weak execution of the spill remediation plan by the Issues Management Team and weak Braidwood Senior Management review and oversight of spill response activities. (Root
However, no historical documentation could be located. to demonstrate that the procedures (other than NSP-RP-6101) were fully executed. This indicates weak execution of the spill remediation plan by the Issues Management Team and weak Braidwood Senior Management review and oversight of spill response activities. (Root
                                -Cause 4)
-Cause 4)
The water was pumped back into the B/D line on 11/10/00 and hydrology wells were installed in the area of the 2000 leak to characterize the local hydrology. Based on calculations and conclusions by a professional hydrologist, underground water in the area of VB-2 would take approximately 15 years to flow offsite. IDNS and EPA were informed. Further remediation efforts were not developed after the surface water was removed. Further efforts were limited to the mechanical failure oriented Root Cause Report (RCR) 38237 and the 10 CFR 50.75(g) characterization study. The 10 CFR 50.75(g) study did not sample groundwater for tritium, even though the NSP-RP-6101 procedure and the regulation clearly state to identify all radioisotopes (Failed Barrier 3). This procedure will be strengthened per CA 21. As a result, the groundwater tritium went undetected until the 2005 tritium sampling discovered the groundwater tritium.
The water was pumped back into the B/D line on 11/10/00 and hydrology wells were installed in the area of the 2000 leak to characterize the local hydrology. Based on calculations and conclusions by a professional hydrologist, underground water in the area of VB-2 would take approximately 15 years to flow offsite. IDNS and EPA were informed. Further remediation efforts were not developed after the surface water was removed. Further efforts were limited to the mechanical failure oriented Root Cause Report (RCR) 38237 and the 10 CFR 50.75(g) characterization study. The 10 CFR 50.75(g) study did not sample groundwater for tritium, even though the NSP-RP-6101 procedure and the regulation clearly state to identify all radioisotopes (Failed Barrier 3). This procedure will be strengthened per CA 21. As a result, the groundwater tritium went undetected until the 2005 tritium sampling discovered the groundwater tritium.
This indicates weak Braidwood Senior Management review and oversight of spill response activities. (Root Cause 4)
This indicates weak Braidwood Senior Management review and oversight of spill response activities. (Root Cause 4)
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Cause (describe the cause and Problem         identify whether it is a root cause or a Statement       contributing cause) Basis for Cause Determination Inadequate       Causal Factor 5,     Personnel were not aware of state regulations (35 IAC 620) to revise procedures and response to     contributing         training for these action levels. Additionally, those who would audit the ODCM/REMP unplanned       cause. Personnel     programs were also not aware that the regulatory and procedural deficiencies existed.
Cause (describe the cause and Problem identify whether it is a root cause or a Statement contributing cause)
releases.       were not aware       (See Attachment 10) If the site had been aware of the requirement, then the site would of state             likely have been driven to properly evaluate groundwater.
Basis for Cause Determination Inadequate Causal Factor 5, Personnel were not aware of state regulations (35 IAC 620) to revise procedures and response to contributing training for these action levels. Additionally, those who would audit the ODCM/REMP unplanned cause. Personnel programs were also not aware that the regulatory and procedural deficiencies existed.
releases.
were not aware (See Attachment 10) If the site had been aware of the requirement, then the site would of state likely have been driven to properly evaluate groundwater.
regulations (example: 35 IAC 620)
regulations (example: 35 IAC 620)
Causal Factor 6,     (FB-30) Interviews with individuals indicated that notice to other Site Departments when Notification:       an event occurred did not always occur. This was also observed through a review of the Processes and       corrective actions database, which indicated that valve leakage was not always identified procedures for       in CAP. In the current corrective action process at Exelon, all issues whether communication       organizational or equipment related are entered and tracked in the corrective action not well defined,   program.
Causal Factor 6, (FB-30) Interviews with individuals indicated that notice to other Site Departments when Notification:
an event occurred did not always occur. This was also observed through a review of the Processes and corrective actions database, which indicated that valve leakage was not always identified procedures for in CAP. In the current corrective action process at Exelon, all issues whether communication organizational or equipment related are entered and tracked in the corrective action not well defined, program.
(FB-31) Interviews with individuals indicated that a process for formal notification to the sites of State regulation changes is lacking. This was also observed through a review of applicable regulations and the lack of those regulations being consistently addressed in the ODCM, Reportability Manual, and other applicable procedures.
(FB-31) Interviews with individuals indicated that a process for formal notification to the sites of State regulation changes is lacking. This was also observed through a review of applicable regulations and the lack of those regulations being consistently addressed in the ODCM, Reportability Manual, and other applicable procedures.
Causal Factor 7,     Training does not exist for Operations, Chemistry or RP personnel for specific Training:           responsibilities related to radiological spill response and assessment (reference General training     Attachment 2) has no prompt to have personnel report environmental spills for assessment of radiological conditions.
Causal Factor 7, Training does not exist for Operations, Chemistry or RP personnel for specific Training:
responsibilities related to radiological spill response and assessment (reference General training )
has no prompt to have personnel report environmental spills for assessment of radiological conditions.
Extent of Condition:
Extent of Condition:
All Exelon Nuclear facilities are potentially affected, with added emphasis on Pressurized Water Reactors due to tritium production rates. A Nuclear Event Report (NER 428868-12) will require all Exelon Sites to take actions to research historical spills and determine if tritium remediation is required. The Nuclear Industry will be informed of the issue through a Nuclear Network Operating Experience Report (NNOE 428868-13). Other spill type (Hazardous Material) response procedures were reviewed and determined to have effective guidance through the Hazmat and Environmental programs (Attachments 2 & 8). These programs and procedures will receive further review and update to integrate radiological interfaces (CAPR 3).
All Exelon Nuclear facilities are potentially affected, with added emphasis on Pressurized Water Reactors due to tritium production rates. A Nuclear Event Report (NER 428868-12) will require all Exelon Sites to take actions to research historical spills and determine if tritium remediation is required. The Nuclear Industry will be informed of the issue through a Nuclear Network Operating Experience Report (NNOE 428868-13).
Other spill type (Hazardous Material) response procedures were reviewed and determined to have effective guidance through the Hazmat and Environmental programs (Attachments 2 & 8). These programs and procedures will receive further review and update to integrate radiological interfaces (CAPR 3).
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Cause being addressed                                         Extent of Condition Review CF-I, RC-1,             This condition applies to any site using a similar configuration for blowdown and radioactive release CAPR-1: Significant     path. ATI 428868-13 was created to update the Nuclear Notification Operating Experience (NNOE) vacuum breaker leaks   to communicate this issue to the Nuclear Industry. ATI 428868-12 was created to update the (NER) in 1998 and 2000.       to communicate this issue to all Exelon sites. Issue Reports 00453379 and 00453387 document that Byron and LaSalle Stations have similar CW B/D and make up design configurations.
Cause being addressed Extent of Condition Review CF-I, RC-1, This condition applies to any site using a similar configuration for blowdown and radioactive release CAPR-1: Significant path. ATI 428868-13 was created to update the Nuclear Notification Operating Experience (NNOE) vacuum breaker leaks to communicate this issue to the Nuclear Industry. ATI 428868-12 was created to update the (NER) in 1998 and 2000.
CF-2, RC-2,             This issue applies to all Exelon Nuclear Stations. All sites produce tritium. Pressurized Water CAPR-2: Continuing     Reactors produce a higher amount of tritium due to the usage of boron. ATI 428868-13 was created small vacuum breaker   to update the Nuclear Notification Operating Experience (NNOE) to communicate this issue to the leaks after the 2000   Nuclear Industry. ATI 428868-12 was created to update the Nuclear Event Report (NER) to event.                 communicate this issue to all Exelon sites. Issue Reports 00453379 and 00453387 document that Byron and LaSalle Stations have similar CW B/D and make up design configurations.
to communicate this issue to all Exelon sites. Issue Reports 00453379 and 00453387 document that Byron and LaSalle Stations have similar CW B/D and make up design configurations.
CF-3, RC-3,             This issue applies to all Exelon Nuclear Stations. All sites produce tritium that can possibly migrate CAPR-4 Procedures -     into groundwater. Pressurized Water Reactors produce a higher amount of tritium due to the usage of A lack of integrated   boron. ATI 428868-13 to update the Nuclear Notification Operating Experience (NNOE) to procedural guidance to communicate this issue to the Nuclear Industry. ATI 428868-12 was created to update the Nuclear ensure proper           Event Report (NER) to communicate this issue to all Exelon sites.
CF-2, RC-2, This issue applies to all Exelon Nuclear Stations. All sites produce tritium. Pressurized Water CAPR-2: Continuing Reactors produce a higher amount of tritium due to the usage of boron. ATI 428868-13 was created small vacuum breaker to update the Nuclear Notification Operating Experience (NNOE) to communicate this issue to the leaks after the 2000 Nuclear Industry. ATI 428868-12 was created to update the Nuclear Event Report (NER) to event.
communicate this issue to all Exelon sites. Issue Reports 00453379 and 00453387 document that Byron and LaSalle Stations have similar CW B/D and make up design configurations.
CF-3, RC-3, This issue applies to all Exelon Nuclear Stations. All sites produce tritium that can possibly migrate CAPR-4 Procedures -
into groundwater. Pressurized Water Reactors produce a higher amount of tritium due to the usage of A lack of integrated boron. ATI 428868-13 to update the Nuclear Notification Operating Experience (NNOE) to procedural guidance to communicate this issue to the Nuclear Industry. ATI 428868-12 was created to update the Nuclear ensure proper Event Report (NER) to communicate this issue to all Exelon sites.
recognition, evaluation, and timely mitigation of the spill events.
recognition, evaluation, and timely mitigation of the spill events.
CF-4, RC-4,             This issue applies to all Exelon Nuclear Stations since the review and oversight is controlled by CAPR-3 & 5:             corporate procedures. Other spill type (Hazardous Material) response procedures were reviewed and Weak management         determined to have effective guidance for non radiological programs (Attachment 8). These review and oversight   programs and procedures will receive further review and update to integrate radiological interfaces.
CF-4, RC-4, This issue applies to all Exelon Nuclear Stations since the review and oversight is controlled by CAPR-3 & 5:
of spill response       CAPR 3 (Human Performance) and CAPR 5 (Issues Management) address these issues for all sites.
corporate procedures. Other spill type (Hazardous Material) response procedures were reviewed and Weak management determined to have effective guidance for non radiological programs (Attachment 8). These review and oversight programs and procedures will receive further review and update to integrate radiological interfaces.
of spill response CAPR 3 (Human Performance) and CAPR 5 (Issues Management) address these issues for all sites.
activities.
activities.
CF-5, Regulations:     All sites have the potential for unplanned releases. The event at Braidwood station is one example.
CF-5, Regulations:
Personnel were not       There are numerous other nuclear industry events (OPEX) that resulted in groundwater aware of State         contamination. For this reason, each site must assess the vulnerability of piping leaks and Regulations             contaminating groundwater. This assessment is not limited to those plants that make liquid discharges. The concern is leakage into groundwater - not dose from liquid effluents to a defined outfall release point. Which is to say, that the ODCM does not direct routine measurements for leakage locations that may produce an exposure pathway. Issue Reports 00453379 and 00453387 document that Byron and LaSalle Stations have similar CW B/D and make up design configurations.
All sites have the potential for unplanned releases. The event at Braidwood station is one example.
Personnel were not There are numerous other nuclear industry events (OPEX) that resulted in groundwater aware of State contamination. For this reason, each site must assess the vulnerability of piping leaks and Regulations contaminating groundwater. This assessment is not limited to those plants that make liquid discharges. The concern is leakage into groundwater - not dose from liquid effluents to a defined outfall release point. Which is to say, that the ODCM does not direct routine measurements for leakage locations that may produce an exposure pathway. Issue Reports 00453379 and 00453387 document that Byron and LaSalle Stations have similar CW B/D and make up design configurations.
Corrective Actions 5 through 14 will address this vulnerability at each site.
Corrective Actions 5 through 14 will address this vulnerability at each site.
CF-6, Notification:     This issue applies to all Exelon stations. CAPR 4, CAPR 5, and CA-14 will address this Processes and           vulnerability at each site.
CF-6, Notification:
This issue applies to all Exelon stations. CAPR 4, CAPR 5, and CA-14 will address this Processes and vulnerability at each site.
procedures for communication not well defined.
procedures for communication not well defined.
CF-7, Training:         This issue applies to all Exelon Nuclear Stations. ATI 428868-12 to update the Nuclear Event Report Personnel not all       (NER) to communicate this issue to all Exelon sites.
CF-7, Training:
This issue applies to all Exelon Nuclear Stations. ATI 428868-12 to update the Nuclear Event Report Personnel not all (NER) to communicate this issue to all Exelon sites.
aware of concern with CW B/D piping and secondary side effluents being tritiated water.
aware of concern with CW B/D piping and secondary side effluents being tritiated water.
CW B/D vacuum           Other Exelon/Amergen Nuclear sites were contacted to determine how those plants are configured breaker design           for circulating water blowdown and makeup and if they have experienced any similar problems with vacuum breaker float assembly failures. Byron and LaSalle stations were the only stations confirmed to have circulating water blowdown and makeup systems that utilize vacuum breakers in their design.
CW B/D vacuum Other Exelon/Amergen Nuclear sites were contacted to determine how those plants are configured breaker design for circulating water blowdown and makeup and if they have experienced any similar problems with vacuum breaker float assembly failures. Byron and LaSalle stations were the only stations confirmed to have circulating water blowdown and makeup systems that utilize vacuum breakers in their design.
For circulating water blowdown and makeup systems, the extent of condition is limited to Byron and LaSalle. Reference Byron IR 453379 and LaSalle IR 453387 for the respective site OPEX review.
For circulating water blowdown and makeup systems, the extent of condition is limited to Byron and LaSalle. Reference Byron IR 453379 and LaSalle IR 453387 for the respective site OPEX review.
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Risk Assessment:
Risk Assessment:
Plant-specific nuclear                                         Basis for Determination safety risk consequence None           There are no plant specific risks associated with this issue. There are no risks to the CW Blowdown system as a result of this issue, since the leaking (failed) vacuum breaker assembly would still function o prevent a vacuum from forming and causing damage to the CW Blowdown piping. This issue has no impact for core damage/accident mitigation. The event was reportable under Reportability Manual, SAF 1.9, News Release or Notification of Other Government Agencies.
Plant-specific nuclear Basis for Determination safety risk consequence None There are no plant specific risks associated with this issue. There are no risks to the CW Blowdown system as a result of this issue, since the leaking (failed) vacuum breaker assembly would still function o prevent a vacuum from forming and causing damage to the CW Blowdown piping. This issue has no impact for core damage/accident mitigation. The event was reportable under Reportability Manual, SAF 1.9, News Release or Notification of Other Government Agencies.
Previous Events:
Previous Events:
The only previous event in terms of Braidwood's response to a release of a contaminant to the nearby environment would be PIF A2000-02683, Oil in North Runoff, where waste oil from an oil separator overflow entered a ditch which formed the boundary between Braidwood Station and Godley on the Station's west side. However investigation of this event by Braidwood Station and Illinois EPA did not identify any contamination of surface or groundwater in Godley. This event is listed in the table below as part of the discussion of events found in the search of the INPO web site.
The only previous event in terms of Braidwood's response to a release of a contaminant to the nearby environment would be PIF A2000-02683, Oil in North Runoff, where waste oil from an oil separator overflow entered a ditch which formed the boundary between Braidwood Station and Godley on the Station's west side. However investigation of this event by Braidwood Station and Illinois EPA did not identify any contamination of surface or groundwater in Godley. This event is listed in the table below as part of the discussion of events found in the search of the INPO web site.
Braidwood has identified 17 leaks from the Circulating Water Blowdown piping, and three of the events, 1996, 1998, and 2000, resulted in flooding of local areas. The previous events table contains a summary of leaks identified from records in the Corrective Action Program and the Work Control Process, including the Station's response. The majority of the blowdown leaks were small (as described in Table 1) and the water does not appear to have overflowed out of the vacuum breaker vault. However, to verify this, wells were drilled in the area of each of the Vacuum Breakers and tritium samples analyzed. The areas around VB-1, VB-2, VB-3, VB-4 and VB-7 have been verified to contain tritium. The entire length of the CW blowdown line has been tested for integrity and found to be intact, with no leaks above the minimum detection limit of 1.0 gpm.
Braidwood has identified 17 leaks from the Circulating Water Blowdown piping, and three of the events, 1996, 1998, and 2000, resulted in flooding of local areas. The previous events table contains a summary of leaks identified from records in the Corrective Action Program and the Work Control Process, including the Station's response.
The majority of the blowdown leaks were small (as described in Table 1) and the water does not appear to have overflowed out of the vacuum breaker vault. However, to verify this, wells were drilled in the area of each of the Vacuum Breakers and tritium samples analyzed. The areas around VB-1, VB-2, VB-3, VB-4 and VB-7 have been verified to contain tritium. The entire length of the CW blowdown line has been tested for integrity and found to be intact, with no leaks above the minimum detection limit of 1.0 gpm.
The INPO website was searched for Operating Experience (OPEX) using the terms tritium, release, offsite, and groundwater. Passport was also searched using similar parameters.
The INPO website was searched for Operating Experience (OPEX) using the terms tritium, release, offsite, and groundwater. Passport was also searched using similar parameters.
There have been numerous events concerning unplanned releases to the environment at numerous sites. For the most part, the descriptions of the, events do not discuss remediation or continuing monitoring, but rather a statement that no activity was released from the site or detected offsite.
There have been numerous events concerning unplanned releases to the environment at numerous sites.
For the most part, the descriptions of the, events do not discuss remediation or continuing monitoring, but rather a statement that no activity was released from the site or detected offsite.
One instance (Pickering, 1997) was found where the licensee attempted to remediate the tritium in the groundwater by flushing the ground with fire protection water. This did not reduce the tritium concentration in the groundwater. Only one event (Waterford, 2003) reported detectable increases in offsite tritium due to a primary to secondary tube leak.
One instance (Pickering, 1997) was found where the licensee attempted to remediate the tritium in the groundwater by flushing the ground with fire protection water. This did not reduce the tritium concentration in the groundwater. Only one event (Waterford, 2003) reported detectable increases in offsite tritium due to a primary to secondary tube leak.
The 2000 overflow of a Braidwood oil separator was included because of its relevance in terms of potential impact to the public and station response.
The 2000 overflow of a Braidwood oil separator was included because of its relevance in terms of potential impact to the public and station response.
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Braidwood Station had no known active leaks and had no increases in any routine radiological environmental samples when low level groundwater radioactivity due to tritium was discovered.
Braidwood Station had no known active leaks and had no increases in any routine radiological environmental samples when low level groundwater radioactivity due to tritium was discovered.
The following are summaries of relevant OPEX events in chronological order:
The following are summaries of relevant OPEX events in chronological order:
Previous Events                                         Previous Event Review INPO Oyster Creek, 1-20-81     Condensate storage and radwaste transfer piping leaks resulted in underground release of radioactive liquid. No remediation was performed.
Previous Events Previous Event Review INPO Oyster Creek, 1-20-81 Condensate storage and radwaste transfer piping leaks resulted in underground release of radioactive liquid. No remediation was performed.
SER 4-81 Hatch, 12-3-86, OE1905,     124,500 gal from a spent fuel pool leak went into the storm drain system and eventually Operating Plant           reached a swamp area within the owner-controlled property. The water discharge resulted Experience                 from a loss of air to the inflatable seals used in the transfer canal between the Units 1 and 2 Spent Fuel Pools. The area was decontaminated, and no activity was detected outside Georgia Power property.
SER 4-81 Hatch, 12-3-86, OE1905, 124,500 gal from a spent fuel pool leak went into the storm drain system and eventually Operating Plant reached a swamp area within the owner-controlled property. The water discharge resulted Experience from a loss of air to the inflatable seals used in the transfer canal between the Units 1 and 2 Spent Fuel Pools. The area was decontaminated, and no activity was detected outside Georgia Power property.
Prairie Island, 5-1-92,   Elevated levels of tritium (concentrations of 1, 300 to 1,500 pCi/L) were detected in an PNO3-92-023, Elevated     onsite groundwater well. Offsite wells sampled showed no increase in-levels of tritium.
Prairie Island, 5-1-92, Elevated levels of tritium (concentrations of 1, 300 to 1,500 pCi/L) were detected in an PNO3-92-023, Elevated onsite groundwater well. Offsite wells sampled showed no increase in-levels of tritium.
levels of tritium detected No further details or follow up actions have been issued on this Preliminary Notification in onsite well             of Occurrence.
levels of tritium detected No further details or follow up actions have been issued on this Preliminary Notification in onsite well of Occurrence.
Dresden, 10-19-94,         Degraded cathodic protection system and breached wrapping of underground piping OE7067, Cathodic           results in through-floor pitting in both contaminated condensate storage tanks and three Protection System         radwaste tanks between 1992 and 1994, through-wall pitting on the HPCI test return line Degeneration               and a demineralized water line, and underground fire protection piping degraded in several areas. The leakage was characterized and a remediation plan to monitor the tritium plume was implemented. No documented review of OE 7067 could be found for Braidwood Station.
Dresden, 10-19-94, Degraded cathodic protection system and breached wrapping of underground piping OE7067, Cathodic results in through-floor pitting in both contaminated condensate storage tanks and three Protection System radwaste tanks between 1992 and 1994, through-wall pitting on the HPCI test return line Degeneration and a demineralized water line, and underground fire protection piping degraded in several areas. The leakage was characterized and a remediation plan to monitor the tritium plume was implemented. No documented review of OE 7067 could be found for Braidwood Station.
Pickering A, 7-18-97,     Since 1979, groundwater at the upgrader plant Pickering A (UPP-A) has had tritium levels SER PD97184, Elevated     in the surrounding groundwater that are above background. Several attempts have been Concentrations of Tritium made to reduce the tritium concentrations in the groundwater including pumping in Groundwater             groundwater with low levels of tritium to the lake and flushing the area with fire protection water. Tritium concentrations in groundwater, however, remained constant.
Pickering A, 7-18-97, Since 1979, groundwater at the upgrader plant Pickering A (UPP-A) has had tritium levels SER PD97184, Elevated in the surrounding groundwater that are above background. Several attempts have been Concentrations of Tritium made to reduce the tritium concentrations in the groundwater including pumping in Groundwater groundwater with low levels of tritium to the lake and flushing the area with fire protection water. Tritium concentrations in groundwater, however, remained constant.
Increased tritium is due to spills and unplanned releases and not taking appropriate action to remediate the area after spills or discharges.
Increased tritium is due to spills and unplanned releases and not taking appropriate action to remediate the area after spills or discharges.
Braidwood, 6-25-00, PIF   Oil separator #1 overflowed into the north runoff and offsite. Root Causes were A2000-02683, Oil in       inadequate preventative maintenance of the north runoff ditch and the oil separator.
Braidwood, 6-25-00, PIF Oil separator #1 overflowed into the north runoff and offsite. Root Causes were A2000-02683, Oil in inadequate preventative maintenance of the north runoff ditch and the oil separator.
North Runoff               Remediation and offsite sampling was performed to mitigate and assess the impact to the public.
North Runoff Remediation and offsite sampling was performed to mitigate and assess the impact to the public.
Limerick, 2-18-02, Event   Tritium concentrations of 10000 pCi/L were detected in the normal waste holding pond.
Limerick, 2-18-02, Event Tritium concentrations of 10000 pCi/L were detected in the normal waste holding pond.
Number 352-020215-1,       There was no plant impact, no personnel exposure, and no release above regulatory limits Tritium Identified in     to the environment. Groundwater monitoring is not performed.
Number 352-020215-1, There was no plant impact, no personnel exposure, and no release above regulatory limits Tritium Identified in to the environment. Groundwater monitoring is not performed.
Normal Waste Water Holding Pond and Auxiliary Boilers 29
Normal Waste Water Holding Pond and Auxiliary Boilers 29


I   Previous Events Previous Event Review Prevous vens                                     Prviou Evnt Rvie Salem, 9-18-02,         Leakage from the Unit 1 Spent Fuel Pool as a result of clogged telltale drains was found.
I Previous Events Previous Event Review Prevous vens Prviou Evnt Rvie Salem, 9-18-02, OE15788, Spent Fuel Pool Leakage, and OE15859 Tritium Detected in Groundwater Samples from Onsite Monitoring Wells (Follow-up to OE15788)
OE15788, Spent Fuel      To determine the affect of the leakage on site groundwater, 8 monitoring wells were Pool Leakage, and        installed as reported on 3-19-03. Tritium results were as high as 69,200 pCi/L in one OE15859 Tritium          sample, and positive results were found in 4 other wells. As reported on 7-25-03, sample Detected in Groundwater  results obtained from new wells indicate tritium concentrations of 3.5M pCi/L and 125K Samples from Onsite      pCi/L. Gamma scans of samples from both locations detected no other radionuclides.
Leakage from the Unit 1 Spent Fuel Pool as a result of clogged telltale drains was found.
Monitoring Wells        There is no indication of any offsite release and there is no threat to the public or company (Follow-up to OE15788)  employees. On 5-3-04, NRC Information Notice 2004-05: Spent Fuel Pool Leakage To Onsite Groundwater is issued describing the Salem event. Braidwood Station does not have any reasonable release paths from our spent fuel pool to the groundwater. The NER issued by Braidwood requires evaluation of all potential tritium spill paths.
To determine the affect of the leakage on site groundwater, 8 monitoring wells were installed as reported on 3-19-03. Tritium results were as high as 69,200 pCi/L in one sample, and positive results were found in 4 other wells. As reported on 7-25-03, sample results obtained from new wells indicate tritium concentrations of 3.5M pCi/L and 125K pCi/L. Gamma scans of samples from both locations detected no other radionuclides.
Waterford, 2-28-03,     Primary to secondary leakage from steam generator tube/tube plug degradation resulted in OE15894, Substantial     an increase in secondary tritium levels and approached a reporting limit listed in the Rising Trend in Tritium Technical Requirements Manual (TRM) for a local drainage canal.
There is no indication of any offsite release and there is no threat to the public or company employees. On 5-3-04, NRC Information Notice 2004-05: Spent Fuel Pool Leakage To Onsite Groundwater is issued describing the Salem event. Braidwood Station does not have any reasonable release paths from our spent fuel pool to the groundwater. The NER issued by Braidwood requires evaluation of all potential tritium spill paths.
Activity Measured at (REMP) Sample Location at Waterford Dresden, 7-31-04,       HPCI suction line had been leaking since Nov 2003. Up to 6M pCi/L was detected in CR248494, High Tritium   monitoring wells and stormdrains on site. Hydrology study shows the event does not Activity In Onsite Wells affect residential wells near the site. Routine monitoring established for 1994 event had and Storm Drains         been discontinued. Remediation consists of quarterly monitoring of plume as it dissipates, verifying it does not migrate off site.
Waterford, 2-28-03, Primary to secondary leakage from steam generator tube/tube plug degradation resulted in OE15894, Substantial an increase in secondary tritium levels and approached a reporting limit listed in the Rising Trend in Tritium Technical Requirements Manual (TRM) for a local drainage canal.
Braidwood, 12-8-04,     Site approaches ODCM quarterly dose limits of 7.5 mrem/unit following the AlR1 I OE19305 / OE19623,       refueling outage due to failed fuel conditions. The cause of challenging the offsite dose Station Challenges       limit is that the effluent release procedures and processes did not have limits or controls in Effluent Quarterly Dose place to account for failed fuel conditions.
Activity Measured at (REMP) Sample Location at Waterford Dresden, 7-31-04, HPCI suction line had been leaking since Nov 2003. Up to 6M pCi/L was detected in CR248494, High Tritium monitoring wells and stormdrains on site. Hydrology study shows the event does not Activity In Onsite Wells affect residential wells near the site. Routine monitoring established for 1994 event had and Storm Drains been discontinued. Remediation consists of quarterly monitoring of plume as it dissipates, verifying it does not migrate off site.
Limits During Unit 1 Outage Watts Bar, 2-8-05,       550,000 pCi/L discovered during routine onsite environmental monitoring. No tritium has OE20318, Onsite         been detected in water samples from offsite monitoring locations, public drinking Groundwater Tritium     supplies, or the Tennessee River. Source is from a Cooling Tower Blowdown Line or Above Reporting Limits   previous leakage from a temporary effluent line.
Braidwood, 12-8-04, Site approaches ODCM quarterly dose limits of 7.5 mrem/unit following the AlR1 I OE19305 / OE19623, refueling outage due to failed fuel conditions. The cause of challenging the offsite dose Station Challenges limit is that the effluent release procedures and processes did not have limits or controls in Effluent Quarterly Dose place to account for failed fuel conditions.
Indian Point, 9-1-05,   Hairline cracks in the liner of the Unit 2 spent fuel pool are found. On 10-5-05 (Event OE21506 Spent Fuel Pool Report 42014), 21100 pCi/L of tritium was detected in monitoring well MW-111 located Hairline Crack           in the Indian Point 2 transformer yard. Other wells showed negative. The sampling that was done was part of an ongoing investigation to verify and quantify previously identified leakage, potentially from the spent fuel pool. Continued sampling discovered tritium in 6 of 9 onsite wells.
Limits During Unit 1 Outage Watts Bar, 2-8-05, 550,000 pCi/L discovered during routine onsite environmental monitoring. No tritium has OE20318, Onsite been detected in water samples from offsite monitoring locations, public drinking Groundwater Tritium supplies, or the Tennessee River. Source is from a Cooling Tower Blowdown Line or Above Reporting Limits previous leakage from a temporary effluent line.
Haddam Neck, 10-31-05,   Spent Fuel Pool leakage to the site groundwater was discovered when removing soil east Event 42099             of the Spent Fuel Building. The quantity of water leaked is unknown. Estimates based on historic Spent Fuel Pool evaporation data indicate that the leak was small - on the order of a few gallons per day. Based on readings from down-gradient monitoring wells, there is no travel offsite.
Indian Point, 9-1-05, Hairline cracks in the liner of the Unit 2 spent fuel pool are found. On 10-5-05 (Event OE21506 Spent Fuel Pool Report 42014), 21100 pCi/L of tritium was detected in monitoring well MW-111 located Hairline Crack in the Indian Point 2 transformer yard. Other wells showed negative. The sampling that was done was part of an ongoing investigation to verify and quantify previously identified leakage, potentially from the spent fuel pool. Continued sampling discovered tritium in 6 of 9 onsite wells.
Haddam Neck, 10-31-05, Spent Fuel Pool leakage to the site groundwater was discovered when removing soil east Event 42099 of the Spent Fuel Building. The quantity of water leaked is unknown. Estimates based on historic Spent Fuel Pool evaporation data indicate that the leak was small - on the order of a few gallons per day. Based on readings from down-gradient monitoring wells, there is no travel offsite.
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Previous Events                                       Previous Event Review EVENTS IDENTIFIED           Description and review of event.
Previous Events Previous Event Review EVENTS IDENTIFIED Description and review of event.
AT BRAIDWOOD STATION 12-5 A1998-04324,   AR written Monday after Southern Div. PR contacted by neighbor. They sighted leaking CW Blowdown Vacuum         vacuum breaker from the south was unaware of the "pond" to the north: Chemistry Breaker Leak - pond of     contacted environmental services. AR status changed to B I due to possibly exceeding water found on property,   release permit limits. This incident was initiated when (name removed) was contacted with standing water in     about the pooled water by a local resident. (Name removed) and (name removed) road ditch along Smiley   investigated and noted the pool was located on station property. There was minor Rd.                       puddling in the adjacent ditch but this water did not run off. Environmental services were consulted and since the ponded area was restricted to station property there was no NPDES concern. The blowdown system was shut down to isolate the vacuum breaker and stop the leakage. WR 980127749 was written to repair the vacuum breaker. The work was performed over the weekend of 12/5. The station response to this event was excellent. Maintenance had this repaired in -24 hrs. This failure had prevented the station from performing liquid releases.
AT BRAIDWOOD STATION 12-5 A1998-04324, AR written Monday after Southern Div. PR contacted by neighbor. They sighted leaking CW Blowdown Vacuum vacuum breaker from the south was unaware of the "pond" to the north: Chemistry Breaker Leak - pond of contacted environmental services. AR status changed to B I due to possibly exceeding water found on property, release permit limits. This incident was initiated when (name removed) was contacted with standing water in about the pooled water by a local resident. (Name removed) and (name removed) road ditch along Smiley investigated and noted the pool was located on station property. There was minor Rd.
11-7 A2000-04281,   The valve had been in this condition for an unknown period of time, most likely several Failed Circulating Water days. The ground in the nearby area is sandy and drains quickly. The ground was Blowdown Vacuum           saturated with water. Upon the discovery of the leak operations isolated CW blowdown Breaker Caused           on the afternoon of 11/6/2000. Draining of the piping to affect the repairs was started on Unplanned Flooding       the morning of 11/7/2000. The 0CW135 (manual isolation to 0CW136) and the 0CW136 Outside the Power Block - CW blowdown vacuum breaker valve were replaced with new valves by 1600 hrs 0CW136 CW blowdown         1 1/7/2000. Once a year a visual inspection of the blowdown and make up lines is valve was found leaking   performed, including the vacuum breakers. The float in question is an internal part and past its main seat.       cannot be inspected without disassembly of the valve. A degraded condition could be found by noting some leakage past the valve seats. This is the first failure of this type. A schedule of replacements will be proposed to the PHC by the system engineer to prevent reoccurrence. Extent Of Condition: the same/similar valve is used in several places on the CW make up and blowdown piping. Byron has a CW makeup and blowdown pipe, however it is not known if Byron has vacuum breakers and if so what type of vacuum breakers. A message was left for the Byron CW system engineer about this problem.
puddling in the adjacent ditch but this water did not run off. Environmental services were consulted and since the ponded area was restricted to station property there was no NPDES concern. The blowdown system was shut down to isolate the vacuum breaker and stop the leakage. WR 980127749 was written to repair the vacuum breaker. The work was performed over the weekend of 12/5. The station response to this event was excellent. Maintenance had this repaired in -24 hrs. This failure had prevented the station from performing liquid releases.
11-17 A2000-04389   The station's response to a December 1998 CW vacuum breaker valve (OCW060) failure (39223), Inadequate       appears to have been inadequate. No evidence can be found to documenting any follow-response to 1998 CW       up sampling, surveys or reporting requirements. PIF# A 1998-04324 details the station' vacuum breaker valve,     response to the 1998 leak. This issue was discovered during the present root cause leak.                     investigation for the CW vacuum breaker valve failure (OCWI136).
11-7 A2000-04281, The valve had been in this condition for an unknown period of time, most likely several Failed Circulating Water days. The ground in the nearby area is sandy and drains quickly. The ground was Blowdown Vacuum saturated with water. Upon the discovery of the leak operations isolated CW blowdown Breaker Caused on the afternoon of 11/6/2000. Draining of the piping to affect the repairs was started on Unplanned Flooding the morning of 11/7/2000. The 0CW135 (manual isolation to 0CW136) and the 0CW136 Outside the Power Block -
11-30 A2000-04465,   Station was slow to implement event response guidelines, CWPI-NSP-AP-1-1, or NGG Slow response to         Issues Management, OP-AA-101-503, for the CW blowdown vacuum breaker failure that implementing Event       was discovered on 11/06/00. NGG Issues Management was not entered until 2+ days Response                 after discovery of the valve failure when rad sample results indicated detectible levels of Guidelines/NGG Issues     particulate radioactivity from the spill.
CW blowdown vacuum breaker valve were replaced with new valves by 1600 hrs 0CW136 CW blowdown 1 1/7/2000. Once a year a visual inspection of the blowdown and make up lines is valve was found leaking performed, including the vacuum breakers. The float in question is an internal part and past its main seat.
cannot be inspected without disassembly of the valve. A degraded condition could be found by noting some leakage past the valve seats. This is the first failure of this type. A schedule of replacements will be proposed to the PHC by the system engineer to prevent reoccurrence. Extent Of Condition: the same/similar valve is used in several places on the CW make up and blowdown piping. Byron has a CW makeup and blowdown pipe, however it is not known if Byron has vacuum breakers and if so what type of vacuum breakers. A message was left for the Byron CW system engineer about this problem.
11-17 A2000-04389 The station's response to a December 1998 CW vacuum breaker valve (OCW060) failure (39223), Inadequate appears to have been inadequate. No evidence can be found to documenting any follow-response to 1998 CW up sampling, surveys or reporting requirements. PIF# A 1998-04324 details the station' vacuum breaker valve, response to the 1998 leak. This issue was discovered during the present root cause leak.
investigation for the CW vacuum breaker valve failure (OCWI136).
11-30 A2000-04465, Station was slow to implement event response guidelines, CWPI-NSP-AP-1-1, or NGG Slow response to Issues Management, OP-AA-101-503, for the CW blowdown vacuum breaker failure that implementing Event was discovered on 11/06/00. NGG Issues Management was not entered until 2+ days
 
===Response===
after discovery of the valve failure when rad sample results indicated detectible levels of Guidelines/NGG Issues particulate radioactivity from the spill.
Management procedure.
Management procedure.
6-18 A2001-01806,   Unauthorized Release Path? [#3 & 11 ]- OCW060 was found seeping water from between CW B/D Valve Leaking. the vacuum breakerfloat and the Buna-N seal. Leakage appears to be about I gal/2 hours.
6-18 A2001-01806, Unauthorized Release Path? [#3 & 11 ]- OCW060 was found seeping water from between CW B/D Valve Leaking.
the vacuum breakerfloat and the Buna-N seal. Leakage appears to be about I gal/2 hours.
As discovered during the investigation of CR# A2000-04281, periodic maintenance of the circulating water blowdown vacuum breaker valves had not previously been up to the standards desired by the station. A campaign was initiated in Q2 2001 to repair/replace as necessary these vacuum breaker valves. When the vaults were opened, four were discovered to contain water (vaults housing OCW060, 0CW144, 0CW075 and 0CW078).
As discovered during the investigation of CR# A2000-04281, periodic maintenance of the circulating water blowdown vacuum breaker valves had not previously been up to the standards desired by the station. A campaign was initiated in Q2 2001 to repair/replace as necessary these vacuum breaker valves. When the vaults were opened, four were discovered to contain water (vaults housing OCW060, 0CW144, 0CW075 and 0CW078).
Radiological analysis of the water revealed 2 of the 4 vaults with radioactive material present in the water (OCW060 and 0CW078 showed activity).
Radiological analysis of the water revealed 2 of the 4 vaults with radioactive material present in the water (OCW060 and 0CW078 showed activity).
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Previous Events                                         Previous Event Review 7-9 A2001-02016     A review of a root cause report titled "Circulating Water Blowdown Line Vacuum (56710), Weaknesses       Breaker Failure Due To Low Stress, High Cycle Fatigue, Resulting In Flooding Of Owner Identified in             Controlled Property And Discharge Outside Of NPDES Approved Path" determined that Documentation of RCR     there were weaknesses associated with the report documentation (reference CR# A2000-For CW Blowdown           04281 .and ATI# 38237). Although the report was well written, the review identified that Valves.                   the description of the Corrective Actions to PreventRecurrence (CAPRS) lacked the clarity needed for mechanical maintenance to understand the full scope of work required to execute the CAPR. Furthermore, it appears that scheduling issues were not fully considered when the due dates were set.
Previous Events Previous Event Review 7-9 A2001-02016 A review of a root cause report titled "Circulating Water Blowdown Line Vacuum (56710), Weaknesses Breaker Failure Due To Low Stress, High Cycle Fatigue, Resulting In Flooding Of Owner Identified in Controlled Property And Discharge Outside Of NPDES Approved Path" determined that Documentation of RCR there were weaknesses associated with the report documentation (reference CR# A2000-For CW Blowdown 04281.and ATI# 38237). Although the report was well written, the review identified that Valves.
5-4 106767, Small   OCW060, CW blowdown vacuum breaker, was identified as having seepage from the vent leak identified from     on the air release valve, (air release valve is part of the entire vacuum breaker assembly OCW060 blowdown valve     but sits adjacent to the main vacuum breaker valve). Main vacuum breaker valve assembly (VB-3)           appeared satisfactory, no leakage. Water level in pit was 30" from top of manhole. No evidence of leakage outside of the manhole was noticed. Water in manhole/pit appears to be a normal condition associated with groundwater infiltration into the manhole.
the description of the Corrective Actions to PreventRecurrence (CAPRS) lacked the clarity needed for mechanical maintenance to understand the full scope of work required to execute the CAPR. Furthermore, it appears that scheduling issues were not fully considered when the due dates were set.
8-20 172376, CW     Main vacuum breaker seat has 1 gpm leak. Water is draining to vacuum breaker pit only Blowdown Vacuum           no area flooding is occurring.
5-4 106767, Small OCW060, CW blowdown vacuum breaker, was identified as having seepage from the vent leak identified from on the air release valve, (air release valve is part of the entire vacuum breaker assembly OCW060 blowdown valve but sits adjacent to the main vacuum breaker valve). Main vacuum breaker valve assembly (VB-3) appeared satisfactory, no leakage. Water level in pit was 30" from top of manhole. No evidence of leakage outside of the manhole was noticed. Water in manhole/pit appears to be a normal condition associated with groundwater infiltration into the manhole.
Breaker 0CW138 has 1 gpm leak (VB-4) 8-27 173204,         Modification testing associated with EC336241 was performed on 8/25/03. The testing OWX26T release with       required a release to be performed from the OWX26T release tank while blowdown flow suspected leakage from   was established at -25,000 gpm. Seat leakage from the 0CW138 blowdown vacuum OCW138 VB-4.             breaker most likely occurred during the time that blowdown flow was at a flow rate of 25,000 gpm. Based on field observations performed on 8/21/03 and 8/27/03 the suspected leakage from the OCW 138 during the time of the OWX26T release was between .25 and 1 gpm, (Note: 0WS26T release occurred between 0630 and 0710 on 8/25/03, Release package L03-104.) Field observations of the 0CW138 were also performed at blowdown flow rates of between 12,000 & 14,000 gpm. These observations indicate that no leakage occurs at these lower flow rates and that the vacuum breaker appears to be open, (Note:
8-20 172376, CW Main vacuum breaker seat has 1 gpm leak. Water is draining to vacuum breaker pit only Blowdown Vacuum no area flooding is occurring.
Breaker 0CW138 has 1 gpm leak (VB-4) 8-27 173204, Modification testing associated with EC336241 was performed on 8/25/03. The testing OWX26T release with required a release to be performed from the OWX26T release tank while blowdown flow suspected leakage from was established at -25,000 gpm. Seat leakage from the 0CW138 blowdown vacuum OCW138 VB-4.
breaker most likely occurred during the time that blowdown flow was at a flow rate of 25,000 gpm. Based on field observations performed on 8/21/03 and 8/27/03 the suspected leakage from the OCW 138 during the time of the OWX26T release was between.25 and 1 gpm, (Note: 0WS26T release occurred between 0630 and 0710 on 8/25/03, Release package L03-104.) Field observations of the 0CW138 were also performed at blowdown flow rates of between 12,000 & 14,000 gpm. These observations indicate that no leakage occurs at these lower flow rates and that the vacuum breaker appears to be open, (Note:
OCW138 open with no leakage indicates that the blowdown pipe is not completely full at the lower flow rates.)
OCW138 open with no leakage indicates that the blowdown pipe is not completely full at the lower flow rates.)
8-29 173688, Water   While performing the annual vacuum breaker surveillance we discovered water in the pit in Vacuum Breaker Pit for containing breaker OCW060. WR # 00110407 was initiated.
8-29 173688, Water While performing the annual vacuum breaker surveillance we discovered water in the pit in Vacuum Breaker Pit for containing breaker OCW060. WR # 00110407 was initiated.
breaker OCW060 [#3].
breaker OCW060 [#3].
9-11 175241,         When CW blowdown was increased per BwOP CW- 12 (to approximately 22,000 gpm, 0CM138 leaking at high   0CW138 was discovered to be leaking at 5 drops per minute.
9-11 175241, When CW blowdown was increased per BwOP CW-12 (to approximately 22,000 gpm, 0CM138 leaking at high 0CW138 was discovered to be leaking at 5 drops per minute.
CW blowdown flow rates
CW blowdown flow rates
[#4].
[#4].
11-17 274328,       While performing OBwOS CW-A1 (CW System B/D and M/U Vacuum Breaker Vacuum Breaker           Inspection) vacuum breaker 0CW069 was popping/leaking. The leakage was small and 0CW069 Is Leaking [#8]. contained within the vacuum breaker's valve pit. Per the Limitations and Actions of the procedure the Shift Manager and RP were notified immediately. Chemistry was notified of the potential for exceeding a limit for NPDES. System Engineering was contacted for guidance and it was determined that the 0CW068 valve would be maintained closed to isolate the vacuum breaker leakage. The System Engineer recommended that two adjacent vacuum breakers not be isolated with CW blowdown in operation. EST (37096)
11-17 274328, While performing OBwOS CW-A1 (CW System B/D and M/U Vacuum Breaker Vacuum Breaker Inspection) vacuum breaker 0CW069 was popping/leaking. The leakage was small and 0CW069 Is Leaking [#8].
contained within the vacuum breaker's valve pit. Per the Limitations and Actions of the procedure the Shift Manager and RP were notified immediately. Chemistry was notified of the potential for exceeding a limit for NPDES. System Engineering was contacted for guidance and it was determined that the 0CW068 valve would be maintained closed to isolate the vacuum breaker leakage. The System Engineer recommended that two adjacent vacuum breakers not be isolated with CW blowdown in operation. EST (37096)
(Equipment status tag) was generated to document the abnormal position.
(Equipment status tag) was generated to document the abnormal position.
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Previous Events                                         Previous Event Review 4-25 328451, Tritium Two samples results from onsite property located on the downstream side of the culvert at Indicated In Samples     the old A entrance gate came back from the vendor with tritium indicated on the results.
Previous Events Previous Event Review 4-25 328451, Tritium Two samples results from onsite property located on the downstream side of the culvert at Indicated In Samples the old A entrance gate came back from the vendor with tritium indicated on the results.
Taken From Onsite         Specifically, the analysis results from Environmental Inc. Midwest Laboratory (EIML)
Taken From Onsite Specifically, the analysis results from Environmental Inc. Midwest Laboratory (EIML)
Culvert.                 indicated results of 539 +/-121 pCi/L tritium (sampled on 03/24/05) and 582.963 +/-
Culvert.
indicated results of 539 +/-121 pCi/L tritium (sampled on 03/24/05) and 582.963 +/-
112.314 pCi/L tritium (sampled on 04/07/05).
112.314 pCi/L tritium (sampled on 04/07/05).
5-18 336401, CW     CW BD Vacuum breaker 0CW058 pilot valve leaking 20 DPM. Need WR to repair.
5-18 336401, CW CW BD Vacuum breaker 0CW058 pilot valve leaking 20 DPM. Need WR to repair.
BD Vacuum Breaker 0CW058 Pilot Valve Leaking 20 DPM [#1].
BD Vacuum Breaker 0CW058 Pilot Valve Leaking 20 DPM [#1].
5-24 338111,         While performing ER-BR-400-101, OCW 140 blowdown vacuum breaker valve was OCW140 Blowdown           observed to have continuous seepage of water from the valve float/seat area. The leakage Vacuum Breaker Valve     is small enough to be contained within the vacuum breaker valve pit with approximately Leaking From Seat [#6. one foot of standing water in the pit.
5-24 338111, While performing ER-BR-400-101, OCW 140 blowdown vacuum breaker valve was OCW140 Blowdown observed to have continuous seepage of water from the valve float/seat area. The leakage Vacuum Breaker Valve is small enough to be contained within the vacuum breaker valve pit with approximately Leaking From Seat [#6.
9-8 371248, NRC     During NRC debrief on 8/31/05, there was discussion regarding the CW blowdown Questions On Previous     vacuum breaker, 0CW058, leakage that was identified in May 2005 (Reference IR Actions With CW B/D       336401). A previous root cause was performed for vacuum breaker failures that occurred vacuum breakers.         in 2000. The NRC question is: Subsequent to 0CW058 leakage identified in May 2005, were the root cause actions reviewed for adequacy? If so, what was the conclusion?
one foot of standing water in the pit.
11-30 428868,       Elevated levels of tritium have recently been identified in certain onsite groundwater Elevated Tritium Levels   sampling wells. The exact source has not been located nor has the source been In Onsite Monitoring     determined to be active or historical.
9-8 371248, NRC During NRC debrief on 8/31/05, there was discussion regarding the CW blowdown Questions On Previous vacuum breaker, 0CW058, leakage that was identified in May 2005 (Reference IR Actions With CW B/D 336401). A previous root cause was performed for vacuum breaker failures that occurred vacuum breakers.
in 2000. The NRC question is: Subsequent to 0CW058 leakage identified in May 2005, were the root cause actions reviewed for adequacy? If so, what was the conclusion?
11-30 428868, Elevated levels of tritium have recently been identified in certain onsite groundwater Elevated Tritium Levels sampling wells. The exact source has not been located nor has the source been In Onsite Monitoring determined to be active or historical.
Wells.
Wells.
NOTE: Review was revalidated on 02/16/06 with no new relevant events found.
NOTE: Review was revalidated on 02/16/06 with no new relevant events found.
Line 433: Line 609:


Corrective Actions to Prevent Recurrence (CAPRs):
Corrective Actions to Prevent Recurrence (CAPRs):
Root Cause Being             Corrective Action to Prevent Recurrence                 Owner           Due Date Addressed                   (CAPR)
Root Cause Being Corrective Action to Prevent Recurrence Owner Due Date Addressed (CAPR)
Causal Factor 1, Root       (CAPR 1: ATI# 38237-08, 38237-17, & 38237-18)           A8930I"         Completed Cause 1: The root cause     Institute a Preventative Maintenance Program and                       03/01/01 of the significant leaks in system modifications, which are complete and have 1998 and 2000 is           been verified to be effective in preventing major valve documented in Root           failures that result in large volume spills.
Causal Factor 1, Root (CAPR 1: ATI# 38237-08, 38237-17, & 38237-18)
Cause Report (RCR) 38237, which determined     [NOTE: On January 15, 2006, a leak occurred on VB-that the Circulating Water   7 due to failure of an internal guide and was (CW) Blowdown (B/D)         documented on IR# 442540. (See analysis section of Vacuum Breaker (VB)         how this issue is addressed) CA-29 will review EACE Valves had inadequate       442540 to ensure corrective actions from 2000 RCR preventative maintenance     38237 & RCR 428868 are still effective.]
A8930I" Completed Cause 1: The root cause Institute a Preventative Maintenance Program and 03/01/01 of the significant leaks in system modifications, which are complete and have 1998 and 2000 is been verified to be effective in preventing major valve documented in Root failures that result in large volume spills.
programs and inadequate design configuration.       Braidwood Station presently performs daily walkdowns of the blowdown vacuum breakers to verify Failed Barrier (FB- 20)     that no leakage is occurring.
Cause Report (RCR) 38237, which determined
Piping/Valves equipment failures Causal Factor 2, Root       (CAPR 2)                                               1) A8901H3     1) 04/03/06 Cause 2: The root cause     1) The Braidwood Tritium Remediation Team will of the small leaks, which   determine the methodology and implement the plan for both preceded and           future radiological releases, including leakage succeeded the 1998 and       standards. (Note: AR 435383) 2000 leaks, was that the need for a near zero         (CAPR 3)                                               2) A8923 and   2) Completed.
[NOTE: On January 15, 2006, a leak occurred on VB-that the Circulating Water 7 due to failure of an internal guide and was (CW) Blowdown (B/D) documented on IR# 442540. (See analysis section of Vacuum Breaker (VB) how this issue is addressed) CA-29 will review EACE Valves had inadequate 442540 to ensure corrective actions from 2000 RCR preventative maintenance 38237 & RCR 428868 are still effective.]
leakage standard was not     2) HU-AA- 102 and HU-AA- 1212, Technical Human         A8961 (approved (Approved for identified, due to a lack of Performance Practices and Technical Task Risk/Rigor     for use at     use at Technical                   Assessment, Pre-Job Brief, Independent Third Party     Braidwood)     Braidwood in Rigor/Questioning           Review, and Post-Job Brief procedures have been                         07/09/04 and Attitude.                   instituted to improve technical rigor, questioning                     07/14/04) attitude, and attention to detail.
programs and inadequate design configuration.
Braidwood Station presently performs daily walkdowns of the blowdown vacuum breakers to verify Failed Barrier (FB-20) that no leakage is occurring.
Piping/Valves equipment failures Causal Factor 2, Root (CAPR 2)
: 1) A8901H3
: 1) 04/03/06 Cause 2: The root cause
: 1) The Braidwood Tritium Remediation Team will of the small leaks, which determine the methodology and implement the plan for both preceded and future radiological releases, including leakage succeeded the 1998 and standards. (Note: AR 435383) 2000 leaks, was that the need for a near zero (CAPR 3)
: 2) A8923 and
: 2) Completed.
leakage standard was not
: 2) HU-AA-102 and HU-AA-1212, Technical Human A8961 (approved (Approved for identified, due to a lack of Performance Practices and Technical Task Risk/Rigor for use at use at Technical Assessment, Pre-Job Brief, Independent Third Party Braidwood)
Braidwood in Rigor/Questioning Review, and Post-Job Brief procedures have been 07/09/04 and Attitude.
instituted to improve technical rigor, questioning 07/14/04) attitude, and attention to detail.
CF-5 Regulations/Oversight FB-33 Weak management review and oversight of spill response activities.
CF-5 Regulations/Oversight FB-33 Weak management review and oversight of spill response activities.
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Root Cause Being           Corrective Action to Prevent Recurrence.                 Owner           Due Date Addressed                 (CAPR)                                                   OwnerDueDat Causal Factor 3, Root     (CAPR 4)                                                 NCS             6/20/06 Cause 3:                   Develop and implement Standard Exelon procedures to     A8015ENV The first root cause for provide integrated and detailed spill and leak response the ineffective response   requirements to ensure full compliance with State and was a lack of integrated . Federal laws and regulations and integrate Exelon procedural guidance to     resources to respond to radiological leaks and spills.
Root Cause Being Corrective Action to Prevent Recurrence.
Owner Due Date Addressed (CAPR)
OwnerDueDat Causal Factor 3, Root (CAPR 4)
NCS 6/20/06 Cause 3:
Develop and implement Standard Exelon procedures to A8015ENV The first root cause for provide integrated and detailed spill and leak response the ineffective response requirements to ensure full compliance with State and was a lack of integrated.
Federal laws and regulations and integrate Exelon procedural guidance to resources to respond to radiological leaks and spills.
ensure proper recognition, evaluation, and timely mitigation of the radiological spill events.
ensure proper recognition, evaluation, and timely mitigation of the radiological spill events.
CF-3 Procedures Failed Barrier (FB)-l BwAP 750-4 FB-2 BwAP1 100-16 FB-3 NSP-RP-6101 FB-4 RP-AA (no specific procedure)
CF-3 Procedures Failed Barrier (FB)-l BwAP 750-4 FB-2 BwAP1 100-16 FB-3 NSP-RP-6101 FB-4 RP-AA (no specific procedure)
FB-6 BwOA ( no specific procedure FB-12 ER-BR-400-101 FB-13 OBwOS CW-A1 FB-14 EN-AA Causal Factor 6 Notification FB-30 Notification to other site departments Causal Factor 4, Root     (CAPR 3)                                                 1) A8923 and   1) Completed Cause 4. A second root     1) HU-AA-102 and - HU-AA-1212, Technical Human           A8961 (approved (Approved for cause for the ineffective Performance Practices and Technical Task Risk/Rigor     for use at     use at response was weak         Assessment, Pre-Job Brief, Independent Third Party       Braidwood)     Braidwood in management review and     Review, and Post-Job Brief procedures have been                         07/09/04 and oversight of spill         instituted to improve technical rigor, questioning                       07/14/04.
FB-6 BwOA ( no specific procedure FB-12 ER-BR-400-101 FB-13 OBwOS CW-A1 FB-14 EN-AA Causal Factor 6 Notification FB-30 Notification to other site departments Causal Factor 4, Root (CAPR 3)
response activities,       attitude, and attention to detail.
: 1) A8923 and
: 1) Completed Cause 4. A second root
: 1) HU-AA-102 and - HU-AA-1212, Technical Human A8961 (approved (Approved for cause for the ineffective Performance Practices and Technical Task Risk/Rigor for use at use at response was weak Assessment, Pre-Job Brief, Independent Third Party Braidwood)
Braidwood in management review and Review, and Post-Job Brief procedures have been 07/09/04 and oversight of spill instituted to improve technical rigor, questioning 07/14/04.
response activities, attitude, and attention to detail.
(CAPR's 3 and 5)
(CAPR's 3 and 5)
(CAPR 5)                                                 2) A8016NGGOP   2) 04/21/06 CF-5                       2) OP-AA-106-101-1002, Exelon Nuclear Issues Regulations/Oversight     Management, will be revised to: 1) improve Corrective FB-33 Weak management     Action Program (CAP) controls of Issues Management review and oversight of   teams, 2) utilize the tools and techniques of the Exelon spill response activities. HU-AA-102 and HU-AA-1212, Technical Human Performance Practices and Technical Task Risk/Rigor Assessment, Pre-Job Brief, Independent Third Party Review, and Post-Job Brief procedures, 3) strengthen reporting requirements to affected station Senior Management, and 4) define affected station Senior Management responsibilities for oversight and challenge of events and issues from initial identification to final disposition.
(CAPR 5)
: 2) A8016NGGOP
: 2) 04/21/06 CF-5
: 2) OP-AA-106-101-1002, Exelon Nuclear Issues Regulations/Oversight Management, will be revised to: 1) improve Corrective FB-33 Weak management Action Program (CAP) controls of Issues Management review and oversight of teams, 2) utilize the tools and techniques of the Exelon spill response activities.
HU-AA-102 and HU-AA-1212, Technical Human Performance Practices and Technical Task Risk/Rigor Assessment, Pre-Job Brief, Independent Third Party Review, and Post-Job Brief procedures, 3) strengthen reporting requirements to affected station Senior Management, and 4) define affected station Senior Management responsibilities for oversight and challenge of events and issues from initial identification to final disposition.
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Effectiveness Reviews (EFRs):
Effectiveness Reviews (EFRs):
Effectiveness CAPR / CA being addressed                               Review Action           Owner     Due Date Causal Factor 1, Root Cause 1: The root cause of the     (EFR 1: 00038237-10)   A8930Tr   Completed significant leaks in 1998 and 2000 is documented in     Perform effectiveness             05/22/2002 Root Cause Report (RCR) 38237, which determined         review of CAPR's under that the Circulating Water (CW) Blowdown (B/D)           ATI# 00038237-Vacuum Breaker (VB) Valves had inadequate               7,8,10,17-20 preventative maintenance programs and inadequate design configuration.
Effectiveness CAPR / CA being addressed Review Action Owner Due Date Causal Factor 1, Root Cause 1: The root cause of the (EFR 1: 00038237-10)
EFR assignment for CAPRs # 2, 3, 4, & 5:                 EFR 2                   A8932CHEM 6/20/07 (CAPR 2) The Braidwood Tritium Remediation Team         Perform effectiveness will determine the methodology and implement the         review of CAPR(s) under plan for future radiological releases, including leakage ATI#428868 for CAPR#
A8930Tr Completed significant leaks in 1998 and 2000 is documented in Perform effectiveness 05/22/2002 Root Cause Report (RCR) 38237, which determined review of CAPR's under that the Circulating Water (CW) Blowdown (B/D)
standards.                                               2,3,4,5 (CAPR 3) HU-AA-102 and HU-AA-1212, Technical Human Performance Practices and Technical Task Risk/Rigor Assessment, Pre-Job Brief, Independent Third Party Review, and Post-Job Brief procedures have been instituted to improve technical rigor, questioning attitude, and attention to detail.
ATI# 00038237-Vacuum Breaker (VB) Valves had inadequate 7,8,10,17-20 preventative maintenance programs and inadequate design configuration.
EFR assignment for CAPRs # 2, 3, 4, & 5:
EFR 2 A8932CHEM 6/20/07 (CAPR 2) The Braidwood Tritium Remediation Team Perform effectiveness will determine the methodology and implement the review of CAPR(s) under plan for future radiological releases, including leakage ATI#428868 for CAPR#
standards.
2,3,4,5 (CAPR 3) HU-AA-102 and HU-AA-1212, Technical Human Performance Practices and Technical Task Risk/Rigor Assessment, Pre-Job Brief, Independent Third Party Review, and Post-Job Brief procedures have been instituted to improve technical rigor, questioning attitude, and attention to detail.
(CAPR 4) Develop and implement Standard Exelon procedures to provide integrated and detailed radiological spill and leak response requirements to ensure full compliance with state and federal laws and regulations and integrate Exelon resources to respond to radiological leaks and spills.
(CAPR 4) Develop and implement Standard Exelon procedures to provide integrated and detailed radiological spill and leak response requirements to ensure full compliance with state and federal laws and regulations and integrate Exelon resources to respond to radiological leaks and spills.
(CAPR 5) OP-AA-106-101-1002, Exelon Nuclear Issues Management, will be revised to: 1) improve Corrective Action Program (CAP) controls of Issues Management teams, 2) utilize the tools and techniques of the Exelon HU-AA- 102 and HU-AA- 1212, Technical Human Performance Practices and Technical Task Risk/Rigor Assessment, Pre-Job Brief, Independent Third Party Review, and Post-Job Brief procedures, 3) strengthen reporting requirements to affected station Senior Management, and 4) define affected station Senior Management responsibilities for oversight and challenge of events and issues from initial identification to final disposition.
(CAPR 5) OP-AA-106-101-1002, Exelon Nuclear Issues Management, will be revised to: 1) improve Corrective Action Program (CAP) controls of Issues Management teams, 2) utilize the tools and techniques of the Exelon HU-AA-102 and HU-AA-1212, Technical Human Performance Practices and Technical Task Risk/Rigor Assessment, Pre-Job Brief, Independent Third Party Review, and Post-Job Brief procedures, 3) strengthen reporting requirements to affected station Senior Management, and 4) define affected station Senior Management responsibilities for oversight and challenge of events and issues from initial identification to final disposition.
MRC assignment for EFR                                   CA-1                   A8932CHEM 6/27/07 Present the EFR to MRC.
MRC assignment for EFR CA-1 A8932CHEM 6/27/07 Present the EFR to MRC.
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Corrective Actions:
Corrective Actions:
Cause Being Addressed             Corrective Action (CA) or Action item (ACIT)               Owner     Due Date Causal Factor 5       CA-2                                                       A8961     08/30/06 Regulations/Oversight Develop a case study of this event. Provide initial and Failed Barrier (FB-33) continuing training for appropriate Braidwood Station and Weak management       Exelon Corporate Management personnel.
Cause Being Addressed Corrective Action (CA) or Action item (ACIT)
review and oversight of radiological spill CA-3                                                       A8961     07/21/06 response activities. Generate a training request for Dynamic Learning Activity (DLA) for all Braidwood Duty Team personnel using 2000 release conditions and revised response and reporting procedures implemented in CAPR4. Create additional assignments as warranted. Report training request action determinations to STC.
Owner Due Date Causal Factor 5 CA-2 A8961 08/30/06 Regulations/Oversight Develop a case study of this event. Provide initial and Failed Barrier (FB-33) continuing training for appropriate Braidwood Station and Weak management Exelon Corporate Management personnel.
CA-4                                                       NCS       05/29/06 Generate a training request to review other potential leaks A8076CHEM beyond tritium to address extent of condition regarding Exelon management's control of hazardous material spills.
review and oversight of radiological spill CA-3 A8961 07/21/06 response activities.
Generate a training request for Dynamic Learning Activity (DLA) for all Braidwood Duty Team personnel using 2000 release conditions and revised response and reporting procedures implemented in CAPR4. Create additional assignments as warranted. Report training request action determinations to STC.
CA-4 NCS 05/29/06 Generate a training request to review other potential leaks A8076CHEM beyond tritium to address extent of condition regarding Exelon management's control of hazardous material spills.
If deficiencies are noted, write IR's to have those deficiencies addressed. Report training request action determinations to STC.
If deficiencies are noted, write IR's to have those deficiencies addressed. Report training request action determinations to STC.
Causal Factor 5.       CA-5                                                       NCS       05/29/06 Regulations/ Oversight Revise the Midwest ODCM and/or program procedures to       A8076CHEM FB-27 Title 35 IAC     incorporate the State of IL requirement of <20,000 pCi/L part 620 groundwater   of tritium for groundwater (35 IAC 620.410.e).3)) and the quality               State of IL requirement for non-degradation (35 IAC 620.301.a))
Causal Factor 5.
CA-6                                                       NCS       05/29/06 Revise the ODCM and/or program procedures as               A8076CHEM warranted to incorporate the State of PA requirements for radioactivity in groundwater.
CA-5 NCS 05/29/06 Regulations/ Oversight Revise the Midwest ODCM and/or program procedures to A8076CHEM FB-27 Title 35 IAC incorporate the State of IL requirement of <20,000 pCi/L part 620 groundwater of tritium for groundwater (35 IAC 620.410.e).3)) and the quality State of IL requirement for non-degradation (35 IAC 620.301.a))
CA-7                                                       NCS       05/29/06 Revise the ODCM and/or program procedures as               A8076CHEM warranted to incorporate the State of NJ requirements for radioactivity in-groundwater CA- 8                                                       NCS       05/29/06 Clearly define to each station (extent of condition), the   A8076CHEM changes to the ODCM based on review of Illinois laws governing radioactive contamination of groundwater (potable water). Assign additional corrective actions to ensure site's ODCM reflects and implements applicable regulations.
CA-6 NCS 05/29/06 Revise the ODCM and/or program procedures as A8076CHEM warranted to incorporate the State of PA requirements for radioactivity in groundwater.
CA-9                                                       NCS       05/29/06 Clearly define to each station (extent of condition), the   A8076CBEM changes to the ODCM based on review of Pennsylvania laws governing radioactive contamination of groundwater (potable water). Assign additional corrective actions to ensure site's ODCM reflects and implements applicable regulations.
CA-7 NCS 05/29/06 Revise the ODCM and/or program procedures as A8076CHEM warranted to incorporate the State of NJ requirements for radioactivity in-groundwater CA-8 NCS 05/29/06 Clearly define to each station (extent of condition), the A8076CHEM changes to the ODCM based on review of Illinois laws governing radioactive contamination of groundwater (potable water). Assign additional corrective actions to ensure site's ODCM reflects and implements applicable regulations.
CA-9 NCS 05/29/06 Clearly define to each station (extent of condition), the A8076CBEM changes to the ODCM based on review of Pennsylvania laws governing radioactive contamination of groundwater (potable water). Assign additional corrective actions to ensure site's ODCM reflects and implements applicable regulations.
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37


Cause Being Addressed               Corrective Action (CA) or Action item (ACIT)             Owner     Due Date Causal Factor 5.       CA-10                                                     NCS       05/29/06 Regulations/ Oversight Clearly define to each station (extent of condition), the A8076CHEM Failed Barrier (FB)-27 changes to the ODCM based on review of New Jersey Title 35 IAC part 620   laws governing radioactive contamination of groundwater groundwater quality     (potable water). Assign additional corrective actions to ensure site's ODCM reflects and implements applicable regulations.
Cause Being Addressed Corrective Action (CA) or Action item (ACIT)
Causal Factor 3,       CA- 1                                                     NCS       05/29/06 Procedures             Corporate Regulatory Assurance to perform an extent of     A8002RAPO condition review regarding ODCM, REMP, RETS and FB-7 LS-AA-1020 &     state regulations for needed changes to the Reportability 1110 Reportability     Manual and create additional actions as required.
Owner Due Date Causal Factor 5.
Manual CA-12                                                     NCS       4/14/06 FB-8 LS-AA-1020 &     Corporate Regulatory Assurance to revise the               A8002RAPO 1110 Reportability     Reportability Manual for reporting requirements of 35 Manual                 IAC 611/620 Groundwater Tritium Release Path, 20,000 pCi/L limitations, and Illinois SB241 Community Right to FB-9 LS-AA-1020 &     Know requirements.
CA-10 NCS 05/29/06 Regulations/ Oversight Clearly define to each station (extent of condition), the A8076CHEM Failed Barrier (FB)-27 changes to the ODCM based on review of New Jersey Title 35 IAC part 620 laws governing radioactive contamination of groundwater groundwater quality (potable water). Assign additional corrective actions to ensure site's ODCM reflects and implements applicable regulations.
1110 Reportability Manual Causal Factor 5,       CA- 13                                                     NCS       06/28/06 Regulations/ Oversight Revise CY-AA-170-000 and associated procedures to         A8076CHEM require audits of the ODCM against applicable laws and FB-28 Corporate       regulations at.an acceptable frequency. Review the need Oversight             for revision to include State regulations into Step 4.2.1 basis of the ODCM. Create additional actions as warranted.
Causal Factor 3, CA-1 NCS 05/29/06 Procedures Corporate Regulatory Assurance to perform an extent of A8002RAPO condition review regarding ODCM, REMP, RETS and FB-7 LS-AA-1020 &
Causal Factor 3,       CA-14                                                     NCS       4/14/06 Procedures             Review the process by which the company becomes aware     A8015 ENV FB-1 1 LS-AA-1020 &   of new environmental laws and regulations for 1110 Reportability     radiological and non-radiological issues and how they are Manual                 integrated and communicated into company policies, programs, and procedures. Assign additional actions as necessary, if process changes are needed.
state regulations for needed changes to the Reportability 1110 Reportability Manual and create additional actions as required.
Manual CA-12 NCS 4/14/06 FB-8 LS-AA-1020 &
Corporate Regulatory Assurance to revise the A8002RAPO 1110 Reportability Reportability Manual for reporting requirements of 35 Manual IAC 611/620 Groundwater Tritium Release Path, 20,000 pCi/L limitations, and Illinois SB241 Community Right to FB-9 LS-AA-1020 &
Know requirements.
1110 Reportability Manual Causal Factor 5, CA-13 NCS 06/28/06 Regulations/ Oversight Revise CY-AA-170-000 and associated procedures to A8076CHEM require audits of the ODCM against applicable laws and FB-28 Corporate regulations at.an acceptable frequency. Review the need Oversight for revision to include State regulations into Step 4.2.1 basis of the ODCM. Create additional actions as warranted.
Causal Factor 3, CA-14 NCS 4/14/06 Procedures Review the process by which the company becomes aware A8015 ENV FB-1 1 LS-AA-1020 &
of new environmental laws and regulations for 1110 Reportability radiological and non-radiological issues and how they are Manual integrated and communicated into company policies, programs, and procedures. Assign additional actions as necessary, if process changes are needed.
Causal Factor 5, Regulations/Oversight FB-26 Title 35 IAC part 611 groundwater quality FB-27 Title 35 IAC part 620 groundwater quality Causal Factor 6, Notification FB-31 Notice to sites of new State Regulations 38
Causal Factor 5, Regulations/Oversight FB-26 Title 35 IAC part 611 groundwater quality FB-27 Title 35 IAC part 620 groundwater quality Causal Factor 6, Notification FB-31 Notice to sites of new State Regulations 38


Programmatic/Organizational Issues:
Programmatic/Organizational Issues:
Programmatic and Organizational             Corrective Action (CA) or Action Item (ACIT)             Owner     Due Date Weaknesses Causal Factor 5,           CA 15                                                     NCS       5115/06 Regulations/Oversight       Evaluate the groundwater and food crop pathway per       A8076CHEM ODCM Table 12.5-1 Section 3.a note (6). Assign Failed Barrier (FB)-24     additional actions as necessary, if the pathway is ODCM requires               credible.
Programmatic and Organizational Corrective Action (CA) or Action Item (ACIT)
evaluation of groundwater pathway if     CA 16                                                     NCS       5/15/06 credible                   Revise the Site specific portions of the ODCM to         A8076CHEM incorporate the new monitoring wells as determined by FB-25 ODCM requires         the ODCM Environmental Specialist to be credible evaluation of               groundwater (well water) monitoring sources into the groundwater pathway if     ODCM Table 11-1 Section 3.a note (6) and ODCM credible                   REMP Table 12.5-1 Section 3a Note (6).
Owner Due Date Weaknesses Causal Factor 5, CA 15 NCS 5115/06 Regulations/Oversight Evaluate the groundwater and food crop pathway per A8076CHEM ODCM Table 12.5-1 Section 3.a note (6). Assign Failed Barrier (FB)-24 additional actions as necessary, if the pathway is ODCM requires credible.
Causal Factor 7, Training   CA 17                                                     A8931RP   3/14/06 Generate TR to develop appropriate training for the RP FB-21 Certification of     management and technician level of knowledge Chemistry personnel         regarding the CW B/D system and the radioactivity expected to be present. Refer to the Root Cause Report FB-22 Licensed and         to be used as a case study. If the TR is rejected, report Non-licensed Operator       out to Senior Training Council (STC).
evaluation of groundwater pathway if CA 16 NCS 5/15/06 credible Revise the Site specific portions of the ODCM to A8076CHEM incorporate the new monitoring wells as determined by FB-25 ODCM requires the ODCM Environmental Specialist to be credible evaluation of groundwater (well water) monitoring sources into the groundwater pathway if ODCM Table 11-1 Section 3.a note (6) and ODCM credible REMP Table 12.5-1 Section 3a Note (6).
initial and requalification CA 18                                                     A8932CHEM 3/14/06 training                   Generate TR to develop appropriate training for the chemistry management and technician level of FB-23 Certification of     knowledge regarding the CW B/D system and the RP/HP                       radioactivity expected to be present. Refer to the Root Cause Report to be used as a case study. If the TR is rejected, report out to Senior Training Council (STC).
Causal Factor 7, Training CA 17 A8931RP 3/14/06 Generate TR to develop appropriate training for the RP FB-21 Certification of management and technician level of knowledge Chemistry personnel regarding the CW B/D system and the radioactivity expected to be present. Refer to the Root Cause Report FB-22 Licensed and to be used as a case study. If the TR is rejected, report Non-licensed Operator out to Senior Training Council (STC).
CA 19                                                     A8910OPS 3/14/06 Generate TR to develop appropriate training for the operations personnel level of knowledge regarding the CW B/D system and the radioactivity expected to be present. Refer to the Root Cause Report to be used as a case study. If the TR is rejected, report out to Senior Training Council (STC).
initial and requalification CA 18 A8932CHEM 3/14/06 training Generate TR to develop appropriate training for the chemistry management and technician level of FB-23 Certification of knowledge regarding the CW B/D system and the RP/HP radioactivity expected to be present. Refer to the Root Cause Report to be used as a case study. If the TR is rejected, report out to Senior Training Council (STC).
Causal Factor 3,           CA 20                                                     A8910OPS 5/29/06 Procedures                 Ops to add precautions to BwOP CW-12, BwOP WX 526TI, & BwOP WX-501TI for release shutdown on FB-15 BwOP CW-12           leak to environment and for the release restrictions FB-16 BwOP WX-526T1         dealing with Reportability Manual Section RAD 1.21 FB-17 BwOP WX-501T1         (i.e.: 100 Ci. limit on tritium releases over a 24 hour period).
CA 19 A8910OPS 3/14/06 Generate TR to develop appropriate training for the operations personnel level of knowledge regarding the CW B/D system and the radioactivity expected to be present. Refer to the Root Cause Report to be used as a case study. If the TR is rejected, report out to Senior Training Council (STC).
Causal Factor 3             CA 21                                                     A8931RP   6/1/06 Procedures:                 RP manager to present to peer group changes to FB-3, NSP-RP-6101,         50.75(g) procedure to clearly address actions necessary "10 CFR 50.75(g)(1)         for tritiated water spills, including evaluation for dose Documentation               assessment to the public and initiate follow-up actions Requirements"               as appropriate to track necessary procedure changes.
Causal Factor 3, CA 20 A8910OPS 5/29/06 Procedures Ops to add precautions to BwOP CW-12, BwOP WX 526TI, & BwOP WX-501TI for release shutdown on FB-15 BwOP CW-12 leak to environment and for the release restrictions FB-16 BwOP WX-526T1 dealing with Reportability Manual Section RAD 1.21 FB-17 BwOP WX-501T1 (i.e.: 100 Ci. limit on tritium releases over a 24 hour period).
Causal Factor 3 CA 21 A8931RP 6/1/06 Procedures:
RP manager to present to peer group changes to FB-3, NSP-RP-6101, 50.75(g) procedure to clearly address actions necessary "10 CFR 50.75(g)(1) for tritiated water spills, including evaluation for dose Documentation assessment to the public and initiate follow-up actions Requirements" as appropriate to track necessary procedure changes.
39
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OTHER ISSUES:
OTHER ISSUES:
Other Issues Identified During the Investigation           Corrective Action (CA) or Action Item (ACIT)             Owner   Due Date Other issues: Alarms/   CA-22                                                     A8930TT 03/24/06 Annunciators           Braidwood System Engineering to review operation of       IR435383 the CW. blowdown system and determine the optimum Failed Barrier (FB)-I 8 monitoring scope and frequency of inspection PM's Leak detection of         and walk downs for the System. If applicable, identify vacuum breakers         gaps and create additional ATI's as required.
Other Issues Identified During the Investigation Corrective Action (CA) or Action Item (ACIT)
Other issues:           CA-23                                                     A8930TI 07/14/06 Alarms/Annunciators     Braidwood System Engineering to research and               IR435383 evaluate passive vacuum breaker replacement options FB&#xfd;18 Leak detection of   and present findings to PHC for approval if the CW vacuum breakers         Blowdown system will be used for radwaste releases in the future. If no action is taken, present this fact to MRC.
Owner Due Date Other issues: Alarms/
Other issues: Alarms/   CA-24                                                     A8930TT 07/14/06 Annunciators             System Engineering to work with Design Engineering         IR435383 to research and evaluate viable remote monitoring FB-19 Alarms and         instrumentation systems that can detect lower level Annunciators             external leakage from the blowdown system and automatically notify Braidwood Operations if the CW blowdown system will be used for radiological releases. If no action is taken, present this fact to MRC.
CA-22 A8930TT 03/24/06 Annunciators Braidwood System Engineering to review operation of IR435383 the CW. blowdown system and determine the optimum Failed Barrier (FB)-I 8 monitoring scope and frequency of inspection PM's Leak detection of and walk downs for the System. If applicable, identify vacuum breakers gaps and create additional ATI's as required.
Other issues: Work       CA-25                                                     A8931RP 3/10/06 Orders:                 RP to provide information to Work Planning so that a work standard can be created for work activities that FB-32                   involve potentially tritiated water. This information Model PM work orders     will be used to update PM model work orders and and current work orders current work orders involving potentially tritiated for B/D vacuum           water.
Other issues:
breakers Causal Factor 3         CA-26                                                     NCS     5/29/06 Procedures               Corporate Work Control to implement revision of WC-       A8035OUT AA- 106 to incorporate a higher work priority for FB-5                     response to unplanned low-level radioactive water WC-AA-106               being released to the environment and repairs to Attachment I implies a   release path monitors.
CA-23 A8930TI 07/14/06 Alarms/Annunciators Braidwood System Engineering to research and IR435383 evaluate passive vacuum breaker replacement options FB&#xfd;18 Leak detection of and present findings to PHC for approval if the CW vacuum breakers Blowdown system will be used for radwaste releases in the future. If no action is taken, present this fact to MRC.
"B2" if increased sampling Other issues: Work       CA-27                                                     A8925PLN 4/10/06 Orders                   Using the information provided by RP, create a work standard to be used for work activities that involve FB-32 Model PM work     potentially tritiated water and update PM model work orders and current work orders and current work orders involving potentially orders for B/D vacuum   tritiated water (RWP, sample for tritium, instructions breakers                 for pumping tritiated water).
Other issues: Alarms/
CA-24 A8930TT 07/14/06 Annunciators System Engineering to work with Design Engineering IR435383 to research and evaluate viable remote monitoring FB-19 Alarms and instrumentation systems that can detect lower level Annunciators external leakage from the blowdown system and automatically notify Braidwood Operations if the CW blowdown system will be used for radiological releases. If no action is taken, present this fact to MRC.
Other issues: Work CA-25 A8931RP 3/10/06 Orders:
RP to provide information to Work Planning so that a work standard can be created for work activities that FB-32 involve potentially tritiated water. This information Model PM work orders will be used to update PM model work orders and and current work orders current work orders involving potentially tritiated for B/D vacuum water.
breakers Causal Factor 3 CA-26 NCS 5/29/06 Procedures Corporate Work Control to implement revision of WC-A8035OUT AA-106 to incorporate a higher work priority for FB-5 response to unplanned low-level radioactive water WC-AA-106 being released to the environment and repairs to Attachment I implies a release path monitors.
"B2" if increased sampling Other issues: Work CA-27 A8925PLN 4/10/06 Orders Using the information provided by RP, create a work standard to be used for work activities that involve FB-32 Model PM work potentially tritiated water and update PM model work orders and current work orders and current work orders involving potentially orders for B/D vacuum tritiated water (RWP, sample for tritium, instructions breakers for pumping tritiated water).
40 C-
40 C-


Other Issues Identified During the Investigation             Corrective Action (CA) or Action Item (ACIT)             Owner   Due Date Causal Factor 6,         ACIT-28                                                   A8921NOA 03/28/06 Notification             Discuss this RCR with the Corporate NOS Peer Group to evaluate changing the NOS auditing template Failed Barrier (FB)-29   standard for the ODCM Program. Document results NOS Audit NOSA-           and assign additional actions as required.
Other Issues Identified During the Investigation Corrective Action (CA) or Action Item (ACIT)
BRW-05-08 (AR 287718) November 22, 2005 Causal Factor 1, Root     CA-29                                                     A8930T" 03/28/06 Cause 1                   Review EACE 00442540 to ensure corrective actions from 2000 RCR 38237 & RCR 428868 are still effective Causal Factor 3,         CA-30                                                     A8931RP 11/28/06 Procedures               Review 50.75(g) files to ensure tritium and or any other isotopes are included for all blowdown vacuum FB-3 NSP-RP-6101         breaker water events and perform 50.75(g) evaluation for all blowdown vacuum breakers not previously completed.
Owner Due Date Causal Factor 6, ACIT-28 A8921NOA 03/28/06 Notification Discuss this RCR with the Corporate NOS Peer Group to evaluate changing the NOS auditing template Failed Barrier (FB)-29 standard for the ODCM Program. Document results NOS Audit NOSA-and assign additional actions as required.
Other issues: Procedures CA-31                                                     A8930TT Per CA BwOP CW-12 was revised to undo water hammer                         process FB-20 Piping/valves       corrective actions from the 2000 root cause report.
BRW-05-08 (AR 287718) November 22, 2005 Causal Factor 1, Root CA-29 A8930T" 03/28/06 Cause 1 Review EACE 00442540 to ensure corrective actions from 2000 RCR 38237 & RCR 428868 are still effective Causal Factor 3, CA-30 A8931RP 11/28/06 Procedures Review 50.75(g) files to ensure tritium and or any other isotopes are included for all blowdown vacuum FB-3 NSP-RP-6101 breaker water events and perform 50.75(g) evaluation for all blowdown vacuum breakers not previously completed.
equipment failures       Issue to be addressed under IR 45338 1.
Other issues: Procedures CA-31 A8930TT Per CA BwOP CW-12 was revised to undo water hammer process FB-20 Piping/valves corrective actions from the 2000 root cause report.
01 fl, ODCM               IR 453638 Tritium Remediation Team review the             A8901H3 4/01/06 Reportability review for reportability associated with 12.5.1lA.2 to determine environmental samples     applicability to the environmental groundwater sampling that is occurring as part of their investigation.
equipment failures Issue to be addressed under IR 45338 1.
01 gI, No clear           CA-32                                                     NCS     6/20/06 delineation of           Update Exelon Management Model to define                   A8015ENV responsibilities between responsibilities for low level radioactive spills.
01 fl, ODCM IR 453638 Tritium Remediation Team review the A8901H3 4/01/06 Reportability review for reportability associated with 12.5.1lA.2 to determine environmental samples applicability to the environmental groundwater sampling that is occurring as part of their investigation.
01 gI, No clear CA-32 NCS 6/20/06 delineation of Update Exelon Management Model to define A8015ENV responsibilities between responsibilities for low level radioactive spills.
corporate Environmental and Chemistry for low level radioactive spills.
corporate Environmental and Chemistry for low level radioactive spills.
41
41


Communications Plan:
Communications Plan:
Lessons Learned to         Communication Plan Action                                 Owner     Due Date be Communicated Elevated tritium levels in NER 1                                                     A8932CHEM Complete onsite monitoring wells;   Submit Preliminary NER (NER 1) for this event Elevated tritium levels in NNOE 1                                                     A8932CHEM Complete onsite monitoring wells;   Submit preliminary NNOE (NNOE 1) for this event.
Lessons Learned to Communication Plan Action Owner Due Date be Communicated Elevated tritium levels in NER 1 A8932CHEM Complete onsite monitoring wells; Submit Preliminary NER (NER 1) for this event Elevated tritium levels in NNOE 1 A8932CHEM Complete onsite monitoring wells; Submit preliminary NNOE (NNOE 1) for this event.
Blowdown line,             CA 33                                                     A8932CHEM 03/14/06 Secondary System           Create a station alignment slide that discusses the root Condensate and other       cause and actions for station personnel when they low level tritium system   discover liquid spills/leaks or liquid in areas where-leaks impact to State and   there should not be liquid.
Blowdown line, CA 33 A8932CHEM 03/14/06 Secondary System Create a station alignment slide that discusses the root Condensate and other cause and actions for station personnel when they low level tritium system discover liquid spills/leaks or liquid in areas where-leaks impact to State and there should not be liquid.
Federal regulations for ground/drinking water.
Federal regulations for ground/drinking water.
Elevated tritium levels in NER update (NER 2) per ATI 428868-12                       A8932CHEM 03/03/06 onsite monitoring wells;   Submit supplemental NER (NER 2) for this event Spills of liquids with low which include a requirement for all Exelon sites to; level radioactivity may     1) Review all historical radiological spills/leaks to site impact State and Federal   property outside of the RCA.
Elevated tritium levels in NER update (NER 2) per ATI 428868-12 A8932CHEM 03/03/06 onsite monitoring wells; Submit supplemental NER (NER 2) for this event Spills of liquids with low which include a requirement for all Exelon sites to; level radioactivity may
regulations.               2) Verify tritium concentrations have been determined for the radiological spills/leaks or perform sampling to determine tritium concentrations for each of the radiological spills/leaks.
: 1) Review all historical radiological spills/leaks to site impact State and Federal property outside of the RCA.
regulations.
: 2) Verify tritium concentrations have been determined for the radiological spills/leaks or perform sampling to determine tritium concentrations for each of the radiological spills/leaks.
: 3) Determine impact of spilled tritium on environment.
: 3) Determine impact of spilled tritium on environment.
: 4) Create additional actions as warranted to insure compliance with all Federal and State regulations and laws.
: 4) Create additional actions as warranted to insure compliance with all Federal and State regulations and laws.
Elevated tritium levels in Promulgate NER 2 to Exelon Nuclear Fleet to include:       A8076CHEM 03/13/06 onsite monitoring wells;   Submit supplemental NER for this event which include Spills of liquids with low a requirement for all Exelon sites to; level radioactivity may     1) Review all historical radiological spills/leaks to site impact State and Federal   property outside of the RCA.
Elevated tritium levels in Promulgate NER 2 to Exelon Nuclear Fleet to include:
regulations                 2) Verify tritium concentrations have been determined for the radiological spills/leaks or perform sampling to determine tritium concentrations for each of the radiological spills/leaks.
A8076CHEM 03/13/06 onsite monitoring wells; Submit supplemental NER for this event which include Spills of liquids with low a requirement for all Exelon sites to; level radioactivity may
: 3) Determine impact of spilled tritium on environment Elevated tritium levels in NNOE update (NNOE 2) per ATI 428868-13. Submit             A8932CHEM 03/10/06 onsite monitoring wells;   supplemental NNOE (NNOE 2) for this event Spills of liquids with low level radioactivity may impact State and Federal
: 1) Review all historical radiological spills/leaks to site impact State and Federal property outside of the RCA.
regulations
: 2) Verify tritium concentrations have been determined for the radiological spills/leaks or perform sampling to determine tritium concentrations for each of the radiological spills/leaks.
: 3) Determine impact of spilled tritium on environment Elevated tritium levels in NNOE update (NNOE 2) per ATI 428868-13. Submit A8932CHEM 03/10/06 onsite monitoring wells; supplemental NNOE (NNOE 2) for this event Spills of liquids with low level radioactivity may impact State and Federal
-regulations.
-regulations.
42
42


Root Cause Report ATTACHMENTS
Root Cause Report ATTACHMENTS Title Notes 1
#                    Title                                 Notes 1 Charter                                   Revision 1 for improved scope clarity.
Charter Revision 1 for improved scope clarity.
2 Barrier Analysis 3 Cause & Effect Analysis 4 E&CF Chart 5 Change Analysis 6 Circ water blowdown system background information 7 Tritium plume map 8 Review of Exelon Hazmat spill response procedures 9 Reportability Manual - LS-AA-1020 and LS-AA-1110 10 Summary of Applicable State, Federal, and Offsite Dose Calculation Manual (ODCM)
2 Barrier Analysis 3
Regulations and Requirements for Tritium Releases to the Environment 11 Root Cause Report Quality Checklist 12 VB-2 and VB-3 detailed timelines 43
Cause & Effect Analysis 4
 
E&CF Chart 5
Attachment 1 Page 1 of 3 LS-AA-1 25-1001 Revision Root Cause Investigation Charter (rev 1)
Change Analysis 6
Tritium Release from Braidwood Station with a Potential to Affect the Public Condition Report #:           428868 Sponsoring Manager:           Janice Kuczynski, Chemistry Manager Team Investigator(s):
Circ water blowdown system background information 7
Names                 Position                                 Commitment
Tritium plume map 8
.,Jason Eggart           Braidwood Chemistry Lead Investigator   Full Time
Review of Exelon Hazmat spill response procedures 9
'Tom Leffler            Root Cause Qualified Investigator       Full Time Randy Kalb            Dresden Chemistry Investigator           Part Time IKim Aleshire            Braidwood EP (ODCM) Investigator         Full Time Glen Vickers          LaSalle RP Investigator                 Full Time Scott Kirkland        Quad Cities Investigator                 Part Time Jim Crawford          Braidwood Maintenance Investigator       Full Time John Gumnick          Corporate RP (CHP) Investigator         Part-Time Mike Miller            Braidwood Operations                    Part Time Jeff Burkett          Braidwood Operations                    Part Time
Reportability Manual - LS-AA-1020 and LS-AA-1110 10 Summary of Applicable State, Federal, and Offsite Dose Calculation Manual (ODCM)
)Dan Stroh              Braidwood Engineering                    Full-Time
Regulations and Requirements for Tritium Releases to the Environment 11 Root Cause Report Quality Checklist 12 VB-2 and VB-3 detailed timelines 43 Page 1 of 3 LS-AA-1 25-1001 Revision Root Cause Investigation Charter (rev 1)
,Scott Sklenar          Hydrologist                              Part-Time Scope:
Tritium Release from Braidwood Station with a Potential to Affect the Public Condition Report #:
Sponsoring Manager:
Team Investigator(s):
428868 Janice Kuczynski, Chemistry Manager Names Position Commitment
.,Jason Eggart
'Tom Leffler Randy Kalb IKim Aleshire Glen Vickers Scott Kirkland Jim Crawford John Gumnick Mike Miller Jeff Burkett
) Dan Stroh
,Scott Sklenar Braidwood Chemistry Lead Investigator Root Cause Qualified Investigator Dresden Chemistry Investigator Braidwood EP (ODCM) Investigator LaSalle RP Investigator Quad Cities Investigator Braidwood Maintenance Investigator Corporate RP (CHP) Investigator Braidwood Operations Braidwood Operations Braidwood Engineering Hydrologist Full Time Full Time Part Time Full Time Full Time Part Time Full Time Part-Time Part Time Part Time Full-Time Part-Time Scope:
The scope of the root cause investigation is twofold:
The scope of the root cause investigation is twofold:
The first focus of this root cause team is to determine the root cause(s) of the Tritium releases from Braidwood Station, which, although low level, had a potential to affect the public. This causal determination should include the large volume leaks, which occurred in 1998 and in 2000, as well as the smaller volume leaks, which both followed and preceded the 1998 and 2000 leaks. The responsibility for identifying and operationalizing corrective actions to prevent future unacceptable tritium releases to the environment is being addressed by the Braidwood Tritium Remediation Team under AR 435383.
The first focus of this root cause team is to determine the root cause(s) of the Tritium releases from Braidwood Station, which, although low level, had a potential to affect the public. This causal determination should include the large volume leaks, which occurred in 1998 and in 2000, as well as the smaller volume leaks, which both followed and preceded the 1998 and 2000 leaks. The responsibility for identifying and operationalizing corrective actions to prevent future unacceptable tritium releases to the environment is being addressed by the Braidwood Tritium Remediation Team under AR 435383.
44
44 Page 2 of 3 This root cause team remains responsible for identifying corrective actions to address organizational weaknesses contributing to or causing the releases described above.
 
Attachment 1 Page 2 of 3 This root cause team remains responsible for identifying corrective actions to address organizational weaknesses contributing to or causing the releases described above.
The second focus of this root cause team is to evaluate the effectiveness of Braidwood's response to the circulating water Blowdown leaks, which deposited tritiated water on the ground during 1998 and 2000 as well as during the smaller volume leaks, which both followed and preceded the 1998 and 2000 leaks. If this evaluation determines that Braidwood's response actions were not effective, this root cause team will determine the root cause and appropriate corrective actions for those ineffective response actions. The investigation will review response procedures, regulations, environmental impacts, and managerial effectiveness. As part of this second focus item, the team will review the response to known spills in 1998, 2000 and similar IRs. A review of year 2000 Root Cause corrective action effectiveness will be performed. Specifically, the team will look for any evidence that the actions to prevent recurrence were not effective. An E&CF Chart will be utilized for Change Analysis and Barrier Analysis. Tap Root Analyses will also be utilized.
The second focus of this root cause team is to evaluate the effectiveness of Braidwood's response to the circulating water Blowdown leaks, which deposited tritiated water on the ground during 1998 and 2000 as well as during the smaller volume leaks, which both followed and preceded the 1998 and 2000 leaks. If this evaluation determines that Braidwood's response actions were not effective, this root cause team will determine the root cause and appropriate corrective actions for those ineffective response actions. The investigation will review response procedures, regulations, environmental impacts, and managerial effectiveness. As part of this second focus item, the team will review the response to known spills in 1998, 2000 and similar IRs. A review of year 2000 Root Cause corrective action effectiveness will be performed. Specifically, the team will look for any evidence that the actions to prevent recurrence were not effective. An E&CF Chart will be utilized for Change Analysis and Barrier Analysis. Tap Root Analyses will also be utilized.
To accomplish a timely report delivery, support will be required as noted above in Engineering, Hydrology, Maintenance, Operations, Offsite Dose Assessment, and Technical Writing.
To accomplish a timely report delivery, support will be required as noted above in Engineering, Hydrology, Maintenance, Operations, Offsite Dose Assessment, and Technical Writing.
Line 546: Line 777:
Remediation plans will be developed and implementation initiated.
Remediation plans will be developed and implementation initiated.
The Braidwood Tritium Remediation Team will maintain communications with Exelon, Regulatory personnel, the public, and INPO.
The Braidwood Tritium Remediation Team will maintain communications with Exelon, Regulatory personnel, the public, and INPO.
45
45 Page 3 of 3 Root Cause Report Milestones:
 
: 1.
Attachment 1 Page 3 of 3 Root Cause Report Milestones:
Event Date
: 1. Event Date                                     (11/30/05)
: 2.
: 2. Screening Date                                 (12/07/05)
Screening Date
: 3. Completion of Charter (2 Days from MRC) [-03]   (12/09/05) 3a. Completion of Charter revision                 (02/08/06)
: 3.
: 4. Status Briefing for Charter [-14]               (12/14/05)
Completion of Charter (2 Days from MRC) [-03]
: 5. Two Week Update & Draft RCR for Reviews [-07]   (12/21/05)
3a.
: 6. MRC Update & Draft RCR for Reviews [-08]       (12/28/05)
Completion of Charter revision
: 7. CAPCo Reviews of RCR [-15]                     (12/29/05)
: 4.
: 8. Collegial Reviews of RCR [-15]                 (12/29/05)
Status Briefing for Charter [-14]
: 9. MRC Update & Draft RCR for Reviews [-09]       (01/04/06)
: 5.
: 10. Sponsoring Manager Report Approval [-14]       (01/04/06)
Two Week Update & Draft RCR for Reviews [-07]
: 11. Root Cause delivered to PORC                   (01/24/06)
: 6.
: 12. Review by PORC [-05]                           (01/26/06)
MRC Update & Draft RCR for Reviews [-08]
: 13. Revised Root Cause Report delivered to PORC     (02/20/06)
: 7.
: 14. Revised Root Cause Report Reviewed by PORC     (02/22/06)
CAPCo Reviews of RCR [-15]
: 15. Final Root Cause Investigation Due Date [-04]   (02/23/06)
: 8.
Prepared By:, Tom Leffleri Root Cause Qualified     02/06/06 1,vestigatov (Name)                             (Date)
Collegial Reviews of RCR [-15]
Approved        Carl B. Dunn, Training Director    02/08/06 By:
: 9.
For (Sponsoring Manager)           (Date) 46
MRC Update & Draft RCR for Reviews [-09]
 
: 10.
Attachment 2 Page 1 of 11 Barrier Analysis Failed or ineffective barrier          How Barrier Failed    Why Barrier Failed                    Corrective action to Restore Barrier to Effectiveness Procedures            CF 3_
Sponsoring Manager Report Approval [-14]
BwAP 750-4            - Hazmat was not    Lack of knowledge of    - Develop and implement Standard Exelon procedures to provide integrated and entered              Title 35 IAC part 620    detailed spill and leak response requirements to ensure full compliance with state Failed Barrier 1                            groundwater quality      and federal laws and regulations and integrate Exelon resources to respond to (FB-1)                                                               radiological leaks and spills. (CAPR 4)
: 11.
                      - Procedure does not                          - See Training Failed Barrier actions prompt radiological response BwAPll00-16            - Hazmat was not    Lack of knowledge of    -Develop and implement Standard Exelon procedures to provide integrated and (FB-2)                 entered              Title 35 IAC part 620    detailed spill and leak response requirements to ensure full compliance with state groundwater quality      and federal laws and regulations and integrate Exelon resources to respond to radiological leaks and spills. (CAPR 4)
Root Cause delivered to PORC
Procedure does not                          -See Training Failed Barrier-actions prompt radiological response NSP-RP-6101            50.75(g) does not    Lack of knowledge of    - Develop and implement Standard Exelon procedures to provide integrated and (FB-3)                clearly address      Title 35 IAC part 620   detailed spill and leak response requirements to ensure full compliance with state tritium              groundwater quality     and federal laws and regulations and integrate Exelon resources to respond to radiological leaks and spills. (CAPR 4)
: 12.
                                                                    -RP manager to present to peer group changes to 50.75(g) procedure to clearly address actions necessary for tritiated water spills, including evaluation for dose assessment to the public and initiate follow-up actions as appropriate to track necessary procedure changes. (CA-21)
Review by PORC [-05]
                                                                    -Review 50.75(g) files to ensure tritium and or any other isotopes are included for all blowdown vacuum breaker water events and perform 50.75(g) evaluation for all blowdown vacuum breakers not previously completed. (CA-30)
: 13.
                                                                    -See Training Failed Barrier actions 47
Revised Root Cause Report delivered to PORC
 
: 14.
Attachment 2 Page 2 of 11 Barrier Analysis Failed or ineffective barrier        How Barrier Failed    Why Barrier Failed                Corrective action to Restore Barrier to Effectiveness RP-AA                  No guidance for low Lack of knowledge of      Develop and implement Standard Exelon procedures to provide integrated (FB-4)                 level spills        Title 35 IAC part 620     and detailed spill and leak response requirements to ensure full compliance groundwater quality       with state and federal laws and regulations and integrate Exelon resources to respond to radiological leaks and spills. (CAPR-4)
Revised Root Cause Report Reviewed by PORC
                                                                      - See Training Failed Barrier actions WC-AA-106              WC called issues    Lack of knowledge of      - See Training Failed Barrier actions Attachment I implies a "C", not recognizing Title 35 IAC part 620    - Corporate Work Control to implement revision of WC-AA-106 to "B2" if increased      that sampling for    groundwater quality      incorporate a higher work priority for response to low level radioactive water sampling              tritium would be                              being released to the environment. (CA-26)
: 15.
(FB-5)                 required BwOA                  No guidance for low Lack of knowledge of      Develop and implement Standard Exelon procedures to provide integrated (Radiological spill    level spills        Title 35 IAC part 620    and detailed spill and leak response requirements to ensure full compliance procedure does not                         groundwater quality      with state and federal laws and regulations and integrate Exelon resources to exist)                                                               respond to radiological leaks and spills. (CAPR-4)
Final Root Cause Investigation Due Date [-04]
(FB-6)                                                                - See Training Failed Barrier actions LS-AA-1020 & 1110      Does not reflect    Lack of knowledge of      -Corporate Regulatory Assurance to perform an extent of condition review Reportability Manual  ODCM REMP/RETS Title 35 IAC part 620           regarding ODCM, REMP, RETS and state regulations for needed changes to (FB-7)                reporting            groundwater quality       the Reportability Manual and create additional actions as required. (CA-1l) requirements                                  -Corporate Regulatory Assurance to revise the Reportability Manual for reporting requirements of 35 IAC 611/620 Groundwater Tritium Release Path, 20,000 pCi/L limitations, and Illinois SB241 Community Right to Know requirements. (CA-12)
Prepared By:, Tom Leffleri Root Cause Qualified 1,vestigatov (Name)
                                                                      - See Training Failed Barrier actions 48
(11/30/05)
 
(12/07/05)
Attachment 2 Page 3 of 11 Barrier Analysis Failed or ineffective barrier        How Barrier Failed      Why Barrier Failed                Corrective action to Restore Barrier to Effectiveness LS-AA-1020 & 1110 Does not reflect 35      Lack of knowledge of     -Corporate Regulatory Assurance, to perform an extent of condition review Reportability Manual IAC 620                Title 35 IAC part 620     regarding ODCM, REMP, RETS and state regulations for needed changes to (FB-8)                Groundwater Tritium groundwater quality       the Reportability Manual and create additional actions as required. (CA- 11)
(12/09/05)
Release Path, 20,000                          -Corporate Regulatory Assurance to revise the Reportability Manual for pCi/L limitations                              reporting requirements of 35 IAC 611/620 Groundwater Tritium Release Path, 20,000 pCi/L limitations, and Illinois SB241 Community Right to Know requirements. (CA-12)
(02/08/06)
                                                                      - See Training Failed Barrier actions LS-AA-1020 & 1110. ENV 3.26 does not        Lack of knowledge of      -Corporate Regulatory Assurance to perform an extent of condition review Reportability Manual clearly warn of       Title 35 IAC part 620     regarding ODCM, REMP, RETS and state regulations for needed changes to (FB-9)                 tritium groundwater  groundwater quality      the Reportability Manual and create additional actions as required. (CA-1 1) quality standards                              -Corporate Regulatory Assurance to revise the Reportability Manual for reporting requirements of 35 IAC 611/620 Groundwater Tritium Release Path, 20,000 pCi/L limitations, and Illinois SB241 Community Right to Know requirements. (CA-12)
(12/14/05)
                                                                      - See Training Failed Barrier actions LS-AA-1020 & 1110      RAD 1.21, 10OCi      Lack of knowledge of      - See Training Failed Barrier actions Reportability Manual   tritium 24h release  tritium amounts released (FB-10)                limitation not checked LS-AA-1020 & 1110      SAF 1.9 New Right    No program for review    Review the process by which the company becomes aware of new Reportability Manual  to Know legislation  and promulgation of new  environmental laws and regulations for radiological and non-radiological (FB-11)               not reflected,      laws.                     issues and how they are integrated and communicated into company policies, programs, and procedures. Assign additional actions as necessary, if process changes are needed. (CA- 14) 49
(12/21/05)
 
(12/28/05)
Attachment 2 Page 4 of 11 Barrier Analysis Failed or ineffective barrier              How Barrier Failed    Why Barrier Failed        Corrective action to Restore Barrier to Effectiveness ER-BR-400-101        No precaution for     Lack of knowledge of      -Develop and implement Standard Exelon procedures to provide integrated Engineering          tritium groundwater  Title 35 IAC part 620     and detailed spill and leak response requirements to ensure full compliance Walkdown PM          concern              groundwater quality      with state and federal laws and regulations and integrate Exelon resources to Procedure                                                            respond to radiological leaks and spills.
(12/29/05)
(FB-12)                                                              (CAPR-4)
(12/29/05)
                                                                      - See Training Failed Barrier actions OBwOS CW-A1 OPS No precaution for          Lack of knowledge of     Develop and implement Standard Exelon procedures to provide integrated Walkdown PM          tritium groundwater  Title 35 IAC part 620    and detailed spill and leak response requirements to ensure full compliance Procedure            concern              groundwater quality      with state and federal laws and regulations and integrate Exelon resources to (FB-13)                                                              respond to radiological leaks and spills. (CAPR-4)
(01/04/06)
                                                                      - See Training Failed Barrier actions EN-AA-Environmental No guidance for         Lack of knowledge of     -Develop and implement Standard Exelon procedures to provide integrated procedures            radiological spills  Title 35 IAC part 620    and detailed spill. and leak response requirements to ensure full compliance (FB-14)               that can get to      groundwater quality      with state and federal laws and regulations and integrate Exelon resources to drinking water                                  respond to radiological leaks and spills. (CAPR-4) supplies                                        -See training failed actions barrier actions BwOP CW-12            No shutdown          Lack of knowledge of     - Ops to add precautions to BwOP CW-12, BwOP WX-526TI, & BwOP WX-(FB-15)              precautions during a  Title 35 IAC part 620    501TI for release shutdown on leak to environment and for the release release for a leak in groundwater quality       restrictions dealing with Reportability Manual Section RAD 1.21 (i.e.: 100 the blowdown system                            Ci. limit on tritium releases over a 24 hour period). (CA-20)
(01/04/06)
                                                                      -See training failed barrier actions BwOP WX-526TI,        No shutdown          Lack of knowledge of     - Ops to add precautions to BwOP CW-12, BwOP WX-526TI, & BwOP WX-(FB-16)              precautions during a Title 35 IAC part 620     501TI for release shutdown on leak to environment and for the release release for a leak in groundwater quality       restrictions dealing with Reportability Manual Section RAD 1.21 (i.e.: 100 the blowdown system                            Ci. limit on tritium releases over a 24 hour period). (CA-20)
(01/24/06)
                                                                      -See training failed  barrier 50
(01/26/06)
 
(02/20/06)
Attachment 2 Page 5 of 11 Barrier Analysis Failed or ineffective barrier              How Barrier Failed Why Barrier Failed                                      Corrective action to Restore Barrier to Effectiveness BwOP WX-501TI        No shutdown          Lack of knowledge of Title 35 IAC part 620          - Ops to add precautions to BwOP CW- 12, BwOP WX-526TI, (FB-17)               precautions during a groundwater quality                                  & BwOP WX-501TI for release shutdown on leak to release for a leak in                                                     environment and for the release restrictions dealing with the blowdown system                                                        Reportability Manual Section RAD 1.21 (i.e.: 100 Ci. limit on tritium releases over a 24 hour period). (CA-20)
(02/22/06)
                                                                                                - See training failed barrier actions Alarms/              Other Issue Annunciators "a" Leak detection on    Only performed       Not often enough to detect leaks. System has        Braidwood System Engineering to review operation of the CW vacuum breakers      annually at the time  inherent suspended materials in the CW, which        lowdown system and determine the optimum monitoring scope (FB-18)               of the 1998 event,    can cause the valves to stick open, allowing        nd frequency of inspection PM's and walk downs for the Recently performed    tritiated water to be released.                     ,ystem. If applicable, identify gaps and create additional ATI's on semi-annual basis.                                                      s required (CA-22)
(02/23/06) 02/06/06 (Date)
Currently (Since Sept. 2005)                                                                -Braidwood System Engineering to research and evaluate performed monthly                                                         passive vacuum breaker replacement options and present findings to PHC for approval if the CW Blowdown system will be used for radiological releases in the future (CA-23)
Approved By:
Alarms and           Did not alarm         Did not exist. Neither the Operations Department,       System Engineering to work with Design Engineering to annunciators                               which is responsible for operating and monitoring       research and evaluate viable remote monitoring (FB-19)                                     the CW B/D System, nor Plant Engineering, which         instrumentation systems that can detect lower level external has responsibility for managing the CW B/D               leakage from the blowdown system and automatically notify System, recognized the need for, nor did they           Braidwood Operations if the CW blowdown system will be pursue installation of a remote detection system         used for radiological releases. (CA-24) for each vacuum breaker. Such a system may have allowed earlier detection and isolation of the leaks described in Table 1, which could have reduced environmental impact.
Carl B. Dunn, Training Director 02/08/06 For (Sponsoring Manager)
51
(Date) 46 Page 1 of 11 Barrier Analysis Failed or ineffective barrier How Barrier Failed Why Barrier Failed Corrective action to Restore Barrier to Effectiveness Procedures CF 3_
 
BwAP 750-4
Attachment 2 Page 6of 11 Barrier Analysis
- Hazmat was not Lack of knowledge of
'Failed or ineffective barrier       How Barrier Failed       Why Barrier Failed                 Corrective action to Restore Barrier to Effectiveness Preventative           CF-1 maintenance/
- Develop and implement Standard Exelon procedures to provide integrated and entered Title 35 IAC part 620 detailed spill and leak response requirements to ensure full compliance with state Failed Barrier 1 groundwater quality and federal laws and regulations and integrate Exelon resources to respond to (FB-1) radiological leaks and spills. (CAPR 4)
design configuration Piping/Valves         Water hammer events Changed BwOP-CW12             BwOP CW-12 revised to mitigate water-hammer - revision 14.
- Procedure does not
equipment failures                           and created a water         (Completed, 01/19/01) . Corrective actions reversed by a subsequent (FB-20)                                       hammer issue               revision.
- See Training Failed Barrier actions prompt radiological response BwAPll00-16
- Hazmat was not Lack of knowledge of
-Develop and implement Standard Exelon procedures to provide integrated and (FB-2) entered Title 35 IAC part 620 detailed spill and leak response requirements to ensure full compliance with state groundwater quality and federal laws and regulations and integrate Exelon resources to respond to radiological leaks and spills. (CAPR 4)
Procedure does not
-See Training Failed Barrier-actions prompt radiological response NSP-RP-6101 50.75(g) does not Lack of knowledge of
- Develop and implement Standard Exelon procedures to provide integrated and (FB-3) clearly address Title 35 IAC part 620 detailed spill and leak response requirements to ensure full compliance with state tritium groundwater quality and federal laws and regulations and integrate Exelon resources to respond to radiological leaks and spills. (CAPR 4)
-RP manager to present to peer group changes to 50.75(g) procedure to clearly address actions necessary for tritiated water spills, including evaluation for dose assessment to the public and initiate follow-up actions as appropriate to track necessary procedure changes. (CA-21)
-Review 50.75(g) files to ensure tritium and or any other isotopes are included for all blowdown vacuum breaker water events and perform 50.75(g) evaluation for all blowdown vacuum breakers not previously completed. (CA-30)
-See Training Failed Barrier actions 47 Page 2 of 11 Barrier Analysis Failed or ineffective barrier How Barrier Failed Why Barrier Failed Corrective action to Restore Barrier to Effectiveness RP-AA No guidance for low Lack of knowledge of Develop and implement Standard Exelon procedures to provide integrated (FB-4) level spills Title 35 IAC part 620 and detailed spill and leak response requirements to ensure full compliance groundwater quality with state and federal laws and regulations and integrate Exelon resources to respond to radiological leaks and spills. (CAPR-4)
- See Training Failed Barrier actions WC-AA-106 WC called issues Lack of knowledge of  
- See Training Failed Barrier actions Attachment I implies a "C", not recognizing Title 35 IAC part 620  
- Corporate Work Control to implement revision of WC-AA-106 to "B2" if increased that sampling for groundwater quality incorporate a higher work priority for response to low level radioactive water sampling tritium would be being released to the environment. (CA-26)
(FB-5) required BwOA No guidance for low Lack of knowledge of Develop and implement Standard Exelon procedures to provide integrated (Radiological spill level spills Title 35 IAC part 620 and detailed spill and leak response requirements to ensure full compliance procedure does not groundwater quality with state and federal laws and regulations and integrate Exelon resources to exist) respond to radiological leaks and spills. (CAPR-4)
(FB-6)  
- See Training Failed Barrier actions LS-AA-1020 & 1110 Does not reflect Lack of knowledge of
-Corporate Regulatory Assurance to perform an extent of condition review Reportability Manual ODCM REMP/RETS Title 35 IAC part 620 regarding ODCM, REMP, RETS and state regulations for needed changes to (FB-7) reporting groundwater quality the Reportability Manual and create additional actions as required. (CA-1l) requirements
-Corporate Regulatory Assurance to revise the Reportability Manual for reporting requirements of 35 IAC 611/620 Groundwater Tritium Release Path, 20,000 pCi/L limitations, and Illinois SB241 Community Right to Know requirements. (CA-12)
- See Training Failed Barrier actions 48 Page 3 of 11 Barrier Analysis Failed or ineffective barrier How Barrier Failed Why Barrier Failed Corrective action to Restore Barrier to Effectiveness LS-AA-1020 & 1110 Does not reflect 35 Lack of knowledge of
-Corporate Regulatory Assurance, to perform an extent of condition review Reportability Manual IAC 620 Title 35 IAC part 620 regarding ODCM, REMP, RETS and state regulations for needed changes to (FB-8)
Groundwater Tritium groundwater quality the Reportability Manual and create additional actions as required. (CA-11)
Release Path, 20,000
-Corporate Regulatory Assurance to revise the Reportability Manual for pCi/L limitations reporting requirements of 35 IAC 611/620 Groundwater Tritium Release Path, 20,000 pCi/L limitations, and Illinois SB241 Community Right to Know requirements. (CA-12)
- See Training Failed Barrier actions LS-AA-1020 & 1110. ENV 3.26 does not Lack of knowledge of
-Corporate Regulatory Assurance to perform an extent of condition review Reportability Manual clearly warn of Title 35 IAC part 620 regarding ODCM, REMP, RETS and state regulations for needed changes to (FB-9) tritium groundwater groundwater quality the Reportability Manual and create additional actions as required. (CA-1 1) quality standards
-Corporate Regulatory Assurance to revise the Reportability Manual for reporting requirements of 35 IAC 611/620 Groundwater Tritium Release Path, 20,000 pCi/L limitations, and Illinois SB241 Community Right to Know requirements. (CA-12)
- See Training Failed Barrier actions LS-AA-1020 & 1110 RAD 1.21, 10OCi Lack of knowledge of  
- See Training Failed Barrier actions Reportability Manual tritium 24h release tritium amounts released (FB-10) limitation not checked LS-AA-1020 & 1110 SAF 1.9 New Right No program for review Review the process by which the company becomes aware of new Reportability Manual to Know legislation and promulgation of new environmental laws and regulations for radiological and non-radiological (FB-11) not reflected, laws.
issues and how they are integrated and communicated into company policies, programs, and procedures. Assign additional actions as necessary, if process changes are needed. (CA-14) 49 Page 4 of 11 Barrier Analysis Failed or ineffective barrier How Barrier Failed Why Barrier Failed Corrective action to Restore Barrier to Effectiveness ER-BR-400-101 No precaution for Lack of knowledge of  
-Develop and implement Standard Exelon procedures to provide integrated Engineering tritium groundwater Title 35 IAC part 620 and detailed spill and leak response requirements to ensure full compliance Walkdown PM concern groundwater quality with state and federal laws and regulations and integrate Exelon resources to Procedure respond to radiological leaks and spills.
(FB-12)
(CAPR-4)
- See Training Failed Barrier actions OBwOS CW-A1 OPS No precaution for Lack of knowledge of Develop and implement Standard Exelon procedures to provide integrated Walkdown PM tritium groundwater Title 35 IAC part 620 and detailed spill and leak response requirements to ensure full compliance Procedure concern groundwater quality with state and federal laws and regulations and integrate Exelon resources to (FB-13) respond to radiological leaks and spills. (CAPR-4)
- See Training Failed Barrier actions EN-AA-Environmental No guidance for Lack of knowledge of  
-Develop and implement Standard Exelon procedures to provide integrated procedures radiological spills Title 35 IAC part 620 and detailed spill. and leak response requirements to ensure full compliance (FB-14) that can get to groundwater quality with state and federal laws and regulations and integrate Exelon resources to drinking water respond to radiological leaks and spills. (CAPR-4) supplies
-See training failed actions barrier actions BwOP CW-12 No shutdown Lack of knowledge of
- Ops to add precautions to BwOP CW-12, BwOP WX-526TI, & BwOP WX-(FB-15) precautions during a Title 35 IAC part 620 501TI for release shutdown on leak to environment and for the release release for a leak in groundwater quality restrictions dealing with Reportability Manual Section RAD 1.21 (i.e.: 100 the blowdown system Ci. limit on tritium releases over a 24 hour period). (CA-20)
-See training failed barrier actions BwOP WX-526TI, No shutdown Lack of knowledge of
- Ops to add precautions to BwOP CW-12, BwOP WX-526TI, & BwOP WX-(FB-16) precautions during a Title 35 IAC part 620 501TI for release shutdown on leak to environment and for the release release for a leak in groundwater quality restrictions dealing with Reportability Manual Section RAD 1.21 (i.e.: 100 the blowdown system Ci. limit on tritium releases over a 24 hour period). (CA-20)
-See training failed barrier 50 Page 5 of 11 Barrier Analysis Failed or ineffective barrier How Barrier Failed Why Barrier Failed Corrective action to Restore Barrier to Effectiveness BwOP WX-501TI No shutdown Lack of knowledge of Title 35 IAC part 620
- Ops to add precautions to BwOP CW-12, BwOP WX-526TI, (FB-17) precautions during a groundwater quality
& BwOP WX-501TI for release shutdown on leak to release for a leak in environment and for the release restrictions dealing with the blowdown system Reportability Manual Section RAD 1.21 (i.e.: 100 Ci. limit on tritium releases over a 24 hour period). (CA-20)
- See training failed barrier actions Alarms/
Other Issue Annunciators "a" Leak detection on Only performed Not often enough to detect leaks. System has Braidwood System Engineering to review operation of the CW vacuum breakers annually at the time inherent suspended materials in the CW, which lowdown system and determine the optimum monitoring scope (FB-18) of the 1998 event, can cause the valves to stick open, allowing nd frequency of inspection PM's and walk downs for the Recently performed tritiated water to be released.
,ystem. If applicable, identify gaps and create additional ATI's on semi-annual basis.
s required (CA-22)
Currently (Since Sept. 2005)  
-Braidwood System Engineering to research and evaluate performed monthly passive vacuum breaker replacement options and present findings to PHC for approval if the CW Blowdown system will be used for radiological releases in the future (CA-23)
Alarms and Did not alarm Did not exist. Neither the Operations Department, System Engineering to work with Design Engineering to annunciators which is responsible for operating and monitoring research and evaluate viable remote monitoring (FB-19) the CW B/D System, nor Plant Engineering, which instrumentation systems that can detect lower level external has responsibility for managing the CW B/D leakage from the blowdown system and automatically notify System, recognized the need for, nor did they Braidwood Operations if the CW blowdown system will be pursue installation of a remote detection system used for radiological releases. (CA-24) for each vacuum breaker. Such a system may have allowed earlier detection and isolation of the leaks described in Table 1, which could have reduced environmental impact.
51 Page 6of 11 Barrier Analysis
'Failed or ineffective barrier How Barrier Failed Why Barrier Failed Corrective action to Restore Barrier to Effectiveness Preventative CF-1 maintenance/
design configuration Piping/Valves Water hammer events Changed BwOP-CW12 BwOP CW-12 revised to mitigate water-hammer - revision 14.
equipment failures and created a water (Completed, 01/19/01). Corrective actions reversed by a subsequent (FB-20) hammer issue revision.
Corrective actions to be addressed under IR 453381. (CA-31)
Corrective actions to be addressed under IR 453381. (CA-31)
Inadequate             R Lack of preventative     Institute a Preventative Maintenance Program and system modifications, preventative               maintenance program     which are complete and have been verified to be effective in preventing maintenance                 for these valves       major valve failures that result in large volume spills. (CAPR 1) programs and           v Valves were not inadequate design           designed to handle configuration               the water hammer events Training               CF-7 Certification of       No training on a       Did not know Title 35       Generate TR to analyze the chemistry management and technician level of Chemistry personnel   response to a liquid   IAC part 620 groundwater   knowledge regarding the CW B/D system and the radioactivity expected to (FB-21)               radiological spill for Tritium concentration       be present. Refer to the Root Cause Report to be used as a case siudy.
Inadequate R Lack of preventative Institute a Preventative Maintenance Program and system modifications, preventative maintenance program which are complete and have been verified to be effective in preventing maintenance for these valves major valve failures that result in large volume spills. (CAPR 1) programs and v
requirements of Title limits                     (CA-18) 35 IAC part 620 groundwater quality.
Valves were not inadequate design designed to handle configuration the water hammer events Training CF-7 Certification of No training on a Did not know Title 35 Generate TR to analyze the chemistry management and technician level of Chemistry personnel response to a liquid IAC part 620 groundwater knowledge regarding the CW B/D system and the radioactivity expected to (FB-21) radiological spill for Tritium concentration be present. Refer to the Root Cause Report to be used as a case siudy.
52
requirements of Title limits (CA-18) 35 IAC part 620 groundwater quality.
 
52 Page 7 of 11 Barrier Analysis Failed or ineffective barrier How Barrier Failed Why Barrier Failed Corrective action to Restore Barrier to Effectiveness Licensed and Non-No Environmental Did not know Title 35 Generate TR to analyze the operations personnel level of knowledge licensed Operator spill training for low IAC part 620 groundwater regarding the CW B/D system and the radioactivity expected to be present.
Attachment 2 Page 7 of 11 Barrier Analysis Failed or ineffective barrier         How Barrier Failed       Why Barrier Failed               Corrective action to Restore Barrier to Effectiveness Licensed and Non-       No Environmental       Did not know Title 35     Generate TR to analyze the operations personnel level of knowledge licensed Operator       spill training for low IAC part 620 groundwater regarding the CW B/D system and the radioactivity expected to be present.
initial and level radioactive quality Refer to the Root Cause Report to be used as a case study. (CA-19) requalification training liquids (FB-22)
initial and             level radioactive     quality                   Refer to the Root Cause Report to be used as a case study. (CA-19) requalification training liquids (FB-22)
Certification of RP/HP Lack of cert guide for Did not know Title 35 Generate TR to analyze the RP management and technician level of (FB-23) low level radioactive IAC part 620 groundwater knowledge regarding the CW B/D system and the radioactivity expected to be liquid spills quality.
Certification of RP/HP   Lack of cert guide for Did not know Title 35     Generate TR to analyze the RP management and technician level of (FB-23)                 low level radioactive IAC part 620 groundwater knowledge regarding the CW B/D system and the radioactivity expected to be liquid spills         quality.   -              resent. Refer to the Root Cause Report to be used as a case study. (CA-17)
resent. Refer to the Root Cause Report to be used as a case study. (CA-17)
Regulations             CF-5 ODCM requires           Braidwood has         Did not know Title 35       Evaluate the groundwater and food crop pathway per ODCM Table 12.5-1 evaluation of           demonstrated a         IAC part 620 groundwater     Section 3.a note (6). Assign additional actions as necessary, if the pathway groundwater pathway if credible pathway         tritium concentration       is credible. (CA-15) credible                                       limits (FB-24)
Regulations CF-5 ODCM requires Braidwood has Did not know Title 35 Evaluate the groundwater and food crop pathway per ODCM Table 12.5-1 evaluation of demonstrated a IAC part 620 groundwater Section 3.a note (6). Assign additional actions as necessary, if the pathway groundwater pathway if credible pathway tritium concentration is credible. (CA-15) credible limits (FB-24)
ODCM requires           Braidwood has         Did not know Title 35     Revise the Site specific portions of the ODCM to incorporate the new evaluation of           demonstrated a         LAC part 620 groundwater monitoring wells as determined by the ODCM Environmental Specialist to be groundwater pathway if credible pathway         Tritium concentration     credible groundwater (well water) monitoring sources into the ODCM Table credible                                       limits                   11-1 Section 3.a note (6) and ODCM REMP Table 12.5-1 Section 3a Note (FB-25)                                                                   (6).groundwater. (CA-16)
ODCM requires Braidwood has Did not know Title 35 Revise the Site specific portions of the ODCM to incorporate the new evaluation of demonstrated a LAC part 620 groundwater monitoring wells as determined by the ODCM Environmental Specialist to be groundwater pathway if credible pathway Tritium concentration credible groundwater (well water) monitoring sources into the ODCM Table credible limits 11-1 Section 3.a note (6) and ODCM REMP Table 12.5-1 Section 3a Note (FB-25)
Title 35 IAC part 611 ODCM does not             Did not know Title 35     Review the process by which the company becomes aware of new groundwater quality     reflect state         IAC part 611 groundwater environmental laws and regulations for radiological and non-radiological (FB-26)                 groundwater           quality                   issues and how they are integrated and communicated into company policies, requirements                                     programs, and procedures. Assign additional actions as necessary, if process changes are needed. (CA-14) 53
(6).groundwater. (CA-16)
 
Title 35 IAC part 611 ODCM does not Did not know Title 35 Review the process by which the company becomes aware of new groundwater quality reflect state IAC part 611 groundwater environmental laws and regulations for radiological and non-radiological (FB-26) groundwater quality issues and how they are integrated and communicated into company policies, requirements programs, and procedures. Assign additional actions as necessary, if process changes are needed. (CA-14) 53 Page 8 of 11 Barrier Analysis Failed or ineffective barrier jHow Barrier Failed jWhy Barrier Failed Corrective action to Restore Barrier to Effectiveness Title 35 IAC part 620 groundwater quality (FB-27)
Attachment 2 Page 8 of 11 Barrier Analysis Failed or ineffective barrier               jHow Barrier Failed jWhy Barrier Failed       Corrective action to Restore Barrier to Effectiveness Title 35 IAC part 620 ODCM does not       Did not know Title 35     Revise the Midwest ODCM and/or program procedures to incorporate the groundwater quality    reflect state      IAC part 620 groundwater  State of IL requirement of <20,000 pCi/L of tritium for groundwater (35 IAC (FB-27)                groundwater        quality standards.        620.410.e).3)) and the State of IL requirement for non-degradation (35 IAC requirements.                                620.301.a)) (CA-5)
ODCM does not reflect state groundwater requirements.
Did not know Title 35 IAC part 620 groundwater quality standards.
Revise the Midwest ODCM and/or program procedures to incorporate the State of IL requirement of <20,000 pCi/L of tritium for groundwater (35 IAC 620.410.e).3)) and the State of IL requirement for non-degradation (35 IAC 620.301.a)) (CA-5)
Revise the ODCM and/or program procedures as warranted to incorporate the State of PA requirements for radioactivity in groundwater. (CA-6)
Revise the ODCM and/or program procedures as warranted to incorporate the State of PA requirements for radioactivity in groundwater. (CA-6)
Revise the ODCM and/or program procedures as warranted to incorporate the State of NJ requirements for radioactivity in groundwater (CA-7)
Revise the ODCM and/or program procedures as warranted to incorporate the State of NJ requirements for radioactivity in groundwater (CA-7)
Line 622: Line 906:
Clearly define to each station (extent of condition), the changes to the ODCM based on review of Pennsylvania laws governing radioactive contamination of groundwater (potable water). Assign additional corrective actions to ensure site's ODCM reflects and implements applicable regulations. (CA-9)
Clearly define to each station (extent of condition), the changes to the ODCM based on review of Pennsylvania laws governing radioactive contamination of groundwater (potable water). Assign additional corrective actions to ensure site's ODCM reflects and implements applicable regulations. (CA-9)
Clearly define to each station (extent of condition), the changes to the ODCM based on review of New Jersey laws governing radioactive contamination of groundwater (potable water). Assign additional corrective actions to ensure site's ODCM reflects and implements applicable regulations. (CA-10)
Clearly define to each station (extent of condition), the changes to the ODCM based on review of New Jersey laws governing radioactive contamination of groundwater (potable water). Assign additional corrective actions to ensure site's ODCM reflects and implements applicable regulations. (CA-10)
Review the process by which the company becomes aware of new environmental laws and regulations for radiological and non-radiological issues and how they are integrated and communicated into company policies, programs, and procedures. Assign additional actions as necessary, if process changes are needed. (CA-14) 54
Review the process by which the company becomes aware of new environmental laws and regulations for radiological and non-radiological issues and how they are integrated and communicated into company policies, programs, and procedures. Assign additional actions as necessary, if process changes are needed. (CA-14) 54 Page 9 of 11 Barrier Analysis Failed or ineffective barrier How Barrier Failed Why Barrier Failed Corrective action to Restore Barrier to Effectiveness Corporate Oversight Did not uncover 2 Corporate audits did not Revise CY-AA-170-000 and associated procedures to require audits of the CY-AA-170-000, missing State check program to ODCM against applicable laws and regulations at an acceptable frequency.
 
CY-AA-170-100, regulations or the sufficient detail Review the need for revision to include State regulations into Step 4.2.1 basis CY-AA-170-1000, state groundwater of the ODCM. Create additional actions as warranted. (CA-13) tritium concentration CY-AA-170-200, issue.
Attachment 2 Page 9 of 11 Barrier Analysis Failed or ineffective barrier             .. How Barrier Failed   Why Barrier Failed         Corrective action to Restore Barrier to Effectiveness Corporate Oversight     Did not uncover 2     Corporate audits did not   Revise CY-AA- 170-000 and associated procedures to require audits of the CY-AA-170-000,         missing State         check program to           ODCM against applicable laws and regulations at an acceptable frequency.
CY-AA-170-2000, CY-AA-170-2000, CY-AA-170-300, CY-AA-170-3100.
CY-AA-170-100,         regulations or the   sufficient detail           Review the need for revision to include State regulations into Step 4.2.1 basis CY-AA-170-1000,         state groundwater                                 of the ODCM. Create additional actions as warranted. (CA- 13) tritium concentration CY-AA-170-200,         issue.
CY-AA- 170-2000, CY-AA-170-2000, CY-AA-170-300, CY-AA-170-3100.
(FB-28)
(FB-28)
Notification           CF-6 NOS Audit NOSA-         Did not uncover two   NOS Audit Plan did not     Discuss this RCR with the Corporate NOS Peer Group to evaluate changing BRW-05-08 (AR           (2) missing state     check program to           the NOS auditing template standard for the ODCM Program. Document 2877 18) November 22, regulations or the     sufficient detail, did not results and assign additional actions as required. (ACIT-28) 2005                   state groundwater     verify ODCM met (11-29)                 tritium concentration applicable state issue                 regulations Notice to other Site   Did not always       No procedure to assure     Develop and implement Standard Exelon procedures to provide integrated Departments when an     inform all affected   consistent approach to     and detailed spill and leak response requirements to ensure full compliance event occurred         parties               leaks/spills               with state and federal laws and regulations and integrate Exelon resources to (FB-30)                                                                   respond to radiological leaks and spills. (CAPR-4) 55
Notification CF-6 NOS Audit NOSA-Did not uncover two NOS Audit Plan did not Discuss this RCR with the Corporate NOS Peer Group to evaluate changing BRW-05-08 (AR (2) missing state check program to the NOS auditing template standard for the ODCM Program. Document 2877 18) November 22, regulations or the sufficient detail, did not results and assign additional actions as required. (ACIT-28) 2005 state groundwater verify ODCM met (11-29) tritium concentration applicable state issue regulations Notice to other Site Did not always No procedure to assure Develop and implement Standard Exelon procedures to provide integrated Departments when an inform all affected consistent approach to and detailed spill and leak response requirements to ensure full compliance event occurred parties leaks/spills with state and federal laws and regulations and integrate Exelon resources to (FB-30) respond to radiological leaks and spills. (CAPR-4) 55 Page 10 of 11 Barrier Analysis Failed or ineffective barrier How Barrier Failed Why Barrier Failed Corrective action to Restore Barrier to Effectiveness Notice to sites of new Sites not informed of Program not robust Review the process by which the company becomes aware of new State Regulations new Illinois SB241, environmental laws and regulations for radiological and non-radiological (FB-31)
 
Community Right to issues and how they are integrated and communicated into company policies, Know programs, and procedures. Assign additional actions as necessary, if process changes are needed. (CA-14)
Attachment 2 Page 10 of 11 Barrier Analysis Failed or ineffective barrier               How Barrier Failed Why Barrier Failed           Corrective action to Restore Barrier to Effectiveness Notice to sites of new Sites not informed of Program not robust       Review the process by which the company becomes aware of new State Regulations     new Illinois SB241,                             environmental laws and regulations for radiological and non-radiological (FB-31)               Community Right to                             issues and how they are integrated and communicated into company policies, Know                                           programs, and procedures. Assign additional actions as necessary, if process changes are needed. (CA- 14)
Work Orders Other Issue Model PM work orders Failed to have RP Did not know Title 35  
Work Orders           Other Issue Model PM work orders   Failed to have RP     Did not know Title 35   - RP to provide information to Work Planning so that a work standard can be and current work       sampling of leaks and IAC part 620 groundwater created for work activities that involve potentially tritiated water. This orders for B/D vacuum how to properly       quality                 information will be used to update PM model work orders and current work breakers               dispose of liquids not                         orders involving potentially triiiated water. (CA-25)
- RP to provide information to Work Planning so that a work standard can be and current work sampling of leaks and IAC part 620 groundwater created for work activities that involve potentially tritiated water. This orders for B/D vacuum how to properly quality information will be used to update PM model work orders and current work breakers dispose of liquids not orders involving potentially triiiated water. (CA-25)
(FB-32)               in work order                                   - Using the information provided by RP, create a work standard to be used for instructions.                                   work activities that involve potentially tritiated water and update PM model work orders and current work orders involving potentially tritiated water (RWP, sample for tritium, instructions for pumping tritiated water). (CA-27) 56
(FB-32) in work order  
 
- Using the information provided by RP, create a work standard to be used for instructions.
Attachment 2 Page 11 of 11 Barrier Analysis Failed or ineffective barrier                 How Barrier Failed Why Barrier Failed           Corrective action to Restore Barrier to Effectiveness Oversight               CF-4 and CF-2 Weak management         CF4: Braidwood         Lack of questioning     OP-AA-106-101-1002, Exelon Nuclear Issues Management, will be revised review and oversight of Senior Management attitude regarding           to: 1) improve Corrective Action Program (CAP) controls of Issues spill response         did not question the unplanned spills from the Management teams, 2) utilize the tools and techniques of the Exelon HU-AA-activities.             radiological impact of blowdown system.         102 and HU-AA-1212, Technical Human Performance Practices and (FB-33)                 all leaks that had                             Technical Task Risk/Rigor Assessment, Pre-Job Brief, Independent Third happened.                                       Party Review, and Post-Job Brief procedures, 3) strengthen reporting requirements to affected station Senior Management, and 4) define affected station Senior Management responsibilities for "cradle to grave" oversight and challenge of events and issues. (CAPR 5)
work activities that involve potentially tritiated water and update PM model work orders and current work orders involving potentially tritiated water (RWP, sample for tritium, instructions for pumping tritiated water). (CA-27) 56 Page 11 of 11 Barrier Analysis Failed or ineffective barrier How Barrier Failed Why Barrier Failed Corrective action to Restore Barrier to Effectiveness Oversight CF-4 and CF-2 Weak management CF4: Braidwood Lack of questioning OP-AA-106-101-1002, Exelon Nuclear Issues Management, will be revised review and oversight of Senior Management attitude regarding to: 1) improve Corrective Action Program (CAP) controls of Issues spill response did not question the unplanned spills from the Management teams, 2) utilize the tools and techniques of the Exelon HU-AA-activities.
CF2: Lack of           Did not know Title 35   The Braidwood Tritium Remediation Team will determine the methodology questioning attitude   IAC part 620 groundwater and implement the plan for future radiological releases, including leakage for low level         Tritium concentration   standards. (CAPR 2) radiological spills. limits                   Develop a case study of this event. Provide initial and continuing training for The need for a near                             MRC/SOC members. (CA-2) zero leakage standard was not identified.                             Evaluate conducting Dynamic Learning Activity (DLA) on a Duty Team basis using 2000 release conditions and revised response and reporting procedures implemented in CAPR 4. Create additional assignments as warranted. (CA-3)
radiological impact of blowdown system.
102 and HU-AA-1212, Technical Human Performance Practices and (FB-33) all leaks that had Technical Task Risk/Rigor Assessment, Pre-Job Brief, Independent Third happened.
Party Review, and Post-Job Brief procedures, 3) strengthen reporting requirements to affected station Senior Management, and 4) define affected station Senior Management responsibilities for "cradle to grave" oversight and challenge of events and issues. (CAPR 5)
CF2: Lack of Did not know Title 35 The Braidwood Tritium Remediation Team will determine the methodology questioning attitude IAC part 620 groundwater and implement the plan for future radiological releases, including leakage for low level Tritium concentration standards. (CAPR 2) radiological spills.
limits Develop a case study of this event. Provide initial and continuing training for The need for a near MRC/SOC members. (CA-2) zero leakage standard was not identified.
Evaluate conducting Dynamic Learning Activity (DLA) on a Duty Team basis using 2000 release conditions and revised response and reporting procedures implemented in CAPR 4. Create additional assignments as warranted. (CA-3)
Review other potential leaks beyond tritium to address extent of condition regarding Exelon management's control of hazardous material spills. If deficiencies are noted, write IR's to have those deficiencies addressed.
Review other potential leaks beyond tritium to address extent of condition regarding Exelon management's control of hazardous material spills. If deficiencies are noted, write IR's to have those deficiencies addressed.
(CA-4) 57
(CA-4) 57 A
 
-Cause & Effect Analysis Effect Symptom Why Cause / Reason Vacuum breaker leaks Small 'leaks were never considered to occurred after 2000 be a problem Small leaks were never 2000 Root Cause Team only considered.to be a problem addressed major failures 2000 Root Cause Team 2000only adr sed TemajThe 2000 charter was to determine the only addressed major major failures failures The charter was narrowly scoped due The 2000 charter was to to two teams were developed to determine the major failures perform the Root Cause and Radiological spill Response The charter was narrowly scoped due to two teams Was not considered a problem as were developed to perform small leaks did not leave the site the Root Cause and Radiological spill Response 58
Attachment 3A
                              -Cause & Effect Analysis Effect Symptom                 Why                             Cause / Reason Vacuum breaker leaks                                   Small 'leaks were never considered to occurred after 2000                                     be a problem Small leaks were never                                 2000 Root Cause Team only considered .to be a problem                             addressed major failures 2000     Root Cause Team 2000only adr   sed TemajThe                                 2000 charter was to determine the only addressed major                                   major failures failures
* The charter was narrowly scoped due The 2000 charter was to                                 to two teams were developed to determine the major failures                           perform the Root Cause and Radiological spill Response The charter was narrowly scoped due to two teams                                 Was not considered a problem as were developed to perform                               small leaks did not leave the site the Root Cause and Radiological spill Response 58


Was not considered a problem as small leaks did               People did not know the 1991 statute not leave the site                       for groundwater.
Was not considered a problem as small leaks did People did not know the 1991 statute not leave the site for groundwater.
The need for a near zero leakage 1991lestatte for                         standard was not identified, due to a gr   d watutefor.                       lack of Technical Rigor/Questioning groundwater.                 &#xf7;Attitude             (Root Cause 2).
The need for a near zero leakage 1991le statte for standard was not identified, due to a gr d watutefor.
The need for a near zero leakage standard was not identified, due to a lack of             At this time the HU-AA-1212 and 102 Technical Rigor/                         procedures did not exist.(CAPR 3)
lack of Technical Rigor/Questioning groundwater.  
&#xf7;Attitude (Root Cause 2).
The need for a near zero leakage standard was not identified, due to a lack of At this time the HU-AA-1212 and 102 Technical Rigor/
procedures did not exist.(CAPR 3)
Questioning Attitude (Root Cause 2).
Questioning Attitude (Root Cause 2).
59
59 B
 
-Cause & Effect Analysis Effect I Symptom Why Cause / Reason Tritium found off site Inadequate response Personnel not aware of the B/D water Tritium exceeding groundwater Inadequate response limits. Belief that release package authorized unrestricted release to environment.
Attachment 3B
Personnel not aware of the B/D water Tritium Personnel not aware of the IEPA exceeding limits. Belief that tritium limit requirements for release package authorized groundwater unrestricted release to environment.
                              -Cause & Effect Analysis Effect I Symptom               Why                     Cause / Reason Tritium found off site                                       Inadequate response Personnel not aware of the B/D water Tritium exceeding groundwater Inadequate response                                 limits. Belief that release package authorized unrestricted release to environment.
Personnel not aware of the JEPA tritium limit Knowledge deficiency requirements for groundwater No integrated procedural guidance for Knowledge deficiency groundwater radiological spills (Root Cause 3) 60 C
Personnel not aware of the B/D water Tritium                                   Personnel not aware of the IEPA exceeding limits. Belief that                               tritium limit requirements for release package authorized                                           groundwater unrestricted release to environment.
-Cause & Effect Analysis Effect I Symptom Why Cause / Reason Tritium found off site Ineffective response in 2000 Ineffective response in Sampling not performed for tritium in 2000 groundwater Sampling not performed for Poor decision by Spill Team not to tritium in groundwater sample Poor decision by Spill Weak questioning attitude and Team not to sample inadequate challenge culture (Root Cause 4)
Personnel not aware of the JEPA tritium limit                                         Knowledge deficiency requirements for groundwater No integrated procedural guidance for Knowledge deficiency                               groundwater radiological spills (Root Cause 3) 60
OP-AA-106-101-1002 (currently, OP-Weak questioning attitude AA-101-503 in year 2000) was not and inadequate challenge specific enough in regarding culture management reporting requirements
 
_(CAPR 5) 61 E&CF Chart
Attachment 3C
:Page 1p~1t fo-itr of birwd~m CSG 000 CF=
                                  -Cause & Effect Analysis Effect I Symptom                   Why                     Cause / Reason Tritium found off site                                     Ineffective response in 2000 Ineffective response in                                 Sampling not performed for tritium in 2000                                                       groundwater Sampling not performed for                                 Poor decision by Spill Team not to tritium in groundwater                                                   sample Poor decision by Spill                                     Weak questioning attitude and Team not to sample                                       inadequate challenge culture (Root Cause 4)
31 SPl&7-kd FO~~p 803 N~h.,
OP-AA-106-101-1002 (currently, OP-Weak questioning attitude                                   AA-101-503 in year 2000) was not and inadequate challenge                                     specific enough in regarding culture                                         management reporting requirements
08,.8,..83.83%5318 83 dh~i503 cI8 3
_(CAPR                                               5) 61 E&CF Chart
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Attachment 5 Change Analysis (The Change Analysis tool was inadequate to use effectively and was therefore not utilized as an input to this root cause report.)
Factors That        Interview        Successful      Failed          Change?  Causal Influence          Questions        Performance    Performance              Factor?
Performance Factors That Influence    Interview      Successful    Failed        Change?  Causal Performance                Questions      Performance    Performance            Factor?
Factors That      Interview        Successful      Failed            Change?  Causal Influence        Questions        Performance      Performance                Factor?
Performance 65


Attachment 6 Page 1 of 6 Circ Water Blowdown System BACKGROUND INFORMATION The primary function of the Circulating Water Blowdown System is to provide for lake turnover to prevent undesirable chemical buildup in the lake. The secondary function of the Circ Water Blowdown System is to provide dilution for liquid rad waste releases. (See Attachment 7 for map.)
pagee~
The Circulating Water Blowdown System is designed to return Cooling Lake water back to the Kankakee River. Processed fluids from the Sewage Treatment System and the Radwaste Treatment Systems discharge directly into the Circulating Water Blowdown system, where dilution occurs prior to release to the Kankakee River. The Wastewater Treatment Plant and the De'mineralizer Regenerant Waste systems along with various strainer/filter backwashes are returned to the Cooling Lake and thus are indirectly returned to the Kankakee River through the Blowdown line after dilution by the Cooling Lake.
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The Circ Water Blowdown system begins at the Circ Water System supply piping to the condenser. Two 24" carbon steel pipes tap off the Circulating Water supply piping (one from each unit) and combine into-a 36" common header. A motor operated isolation valve (1/2CW018) is provided on each 24" line. The 6" Radwaste Treatment System discharge pipe connects to the 36" blowdown header. Downstream of the radwaste connection, the blowdown pipe is expanded to 48" prior to connection to the 3" Sewage Treatment Plant discharge pipe.
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The 48" diameter blowdown pipe is reinforced concrete pipe (RCP) and runs along owner-controlled property until reaching the Blowdown structure at the Kankakee River. Eleven vacuum breaker assemblies are incorporated at the high points along the 48" diameter RCP to prevent pipe implosion when the blowdown system is shut off. The 48" RCP is split and reduced to two 24" discharge pipes at the Kankakee River blowdown structure. Each 24" discharge pipe was originally equipped with a motor operated spray valve. The entire piping network is approximately 29,000 ft long and was originally operated at about 12,000 gpm (-2.5 ft/s).
=
The Circ Water Blowdown system was originally designed to be maintained full of water and pressurized. This was accomplished through manipulation of the Blowdown Spray Valves, at the Kankakee River blowdown structure. These valves were susceptible to freezing due to their location and system operation requirements. Based on this, other maintenance issues, and parts obsolescence, these valves were eventually abandoned in the full open position in the late 66
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Attachment 6 Page 2 of 6 1980's-. To allow-air release from the piping on start-up and to allow air introduction to protect against vacuum damage to the piping, vacuum breakers are installed.
o r~aeledT,-r) st c
                          'VA     EMA9
EF kwt, 33 mlak
* 0j"      N   i.9         I NOTE: Above is typical. Braidwood has 48" reinforced concrete pipe. Other differences may apply.
(
on.t.j fks&*U 64 Change Analysis (The Change Analysis tool was inadequate to use effectively and was therefore not utilized as an input to this root cause report.)
Factors That Interview Successful Failed Change?
Causal Influence Questions Performance Performance Factor?
Performance Factors That Influence Interview Successful Failed Change?
Causal Performance Questions Performance Performance Factor?
Factors That Interview Successful Failed Change?
Causal Influence Questions Performance Performance Factor?
Performance 65 Page 1 of 6 Circ Water Blowdown System BACKGROUND INFORMATION The primary function of the Circulating Water Blowdown System is to provide for lake turnover to prevent undesirable chemical buildup in the lake. The secondary function of the Circ Water Blowdown System is to provide dilution for liquid rad waste releases. (See Attachment 7 for map.)
The Circulating Water Blowdown System is designed to return Cooling Lake water back to the Kankakee River. Processed fluids from the Sewage Treatment System and the Radwaste Treatment Systems discharge directly into the Circulating Water Blowdown system, where dilution occurs prior to release to the Kankakee River.
The Wastewater Treatment Plant and the De'mineralizer Regenerant Waste systems along with various strainer/filter backwashes are returned to the Cooling Lake and thus are indirectly returned to the Kankakee River through the Blowdown line after dilution by the Cooling Lake.
The Circ Water Blowdown system begins at the Circ Water System supply piping to the condenser. Two 24" carbon steel pipes tap off the Circulating Water supply piping (one from each unit) and combine into-a 36" common header. A motor operated isolation valve (1/2CW018) is provided on each 24" line.
The 6" Radwaste Treatment System discharge pipe connects to the 36" blowdown header.
Downstream of the radwaste connection, the blowdown pipe is expanded to 48" prior to connection to the 3" Sewage Treatment Plant discharge pipe.
The 48" diameter blowdown pipe is reinforced concrete pipe (RCP) and runs along owner-controlled property until reaching the Blowdown structure at the Kankakee River.
Eleven vacuum breaker assemblies are incorporated at the high points along the 48" diameter RCP to prevent pipe implosion when the blowdown system is shut off.
The 48" RCP is split and reduced to two 24" discharge pipes at the Kankakee River blowdown structure. Each 24" discharge pipe was originally equipped with a motor operated spray valve. The entire piping network is approximately 29,000 ft long and was originally operated at about 12,000 gpm (-2.5 ft/s).
The Circ Water Blowdown system was originally designed to be maintained full of water and pressurized. This was accomplished through manipulation of the Blowdown Spray Valves, at the Kankakee River blowdown structure. These valves were susceptible to freezing due to their location and system operation requirements. Based on this, other maintenance issues, and parts obsolescence, these valves were eventually abandoned in the full open position in the late 66 Page 2 of 6 1980's-. To allow-air release from the piping on start-up and to allow air introduction to protect against vacuum damage to the piping, vacuum breakers are installed.
'VA EMA9 0j"
* N i.9 I
NOTE: Above is typical. Braidwood has 48" reinforced concrete pipe. Other differences may apply.
System control was transferred to the upstream motor operator isolation valves located in the turbine building. This modification caused the blowdown line to operate in a partially voided condition in various locations, depending on elevation which allowed column separation water hammer events to occur when flow rates were changed significantly, i.e.; during system start-up or shut down.
System control was transferred to the upstream motor operator isolation valves located in the turbine building. This modification caused the blowdown line to operate in a partially voided condition in various locations, depending on elevation which allowed column separation water hammer events to occur when flow rates were changed significantly, i.e.; during system start-up or shut down.
Events were not initially seen because blowdown was essentially in service all the time. As a result of this change in operational methodology, the blowdown system would no longer be maintained full and pressurized upon shutdown.
Events were not initially seen because blowdown was essentially in service all the time. As a result of this change in operational methodology, the blowdown system would no longer be maintained full and pressurized upon shutdown.
Minimal technical review was performed on the hydraulic transient effects on the vacuum breakers from this method of operation.
Minimal technical review was performed on the hydraulic transient effects on the vacuum breakers from this method of operation.
67
67 Page 3 of 6 A more rigorous technical review may have initiated the installation of surge protected check valves (which eventually occurred in 2001) before the majority of the leaks described in this report occurred. This is a missed opportunity.
 
In 1997, the Chemical Feed System was relocated from the Turbine Building to the Lake Screen House under modification M20-0-95-003. One of the primary reasons for centralization of the Chemical Feed system to the Lake Screen House was to reduce maintenance cost.
Attachment 6 Page 3 of 6 A more rigorous technical review may have initiated the installation of surge protected check valves (which eventually occurred in 2001) before the majority of the leaks described in this report occurred. This is a missed opportunity.
This design change necessitated isolating the Circ Water Blowdown System on a daily basis to accommodate biocide injections into the Circ Water System, because our permits do not authorize discharge of biocide to the Kankakee River. When both units were in operation this was not an issue because partial blowdown flow was maintained from the unit not being chlorinated. The problem became apparent during outages when one unit was shut down. In this configuration, blowdown flow was stopped and started whenever the operating unit was chlorinated.
In 1997, the Chemical Feed System was relocated from the Turbine Building to the Lake Screen House under modification M20-0-95-003. One of the primary reasons for centralization of the Chemical Feed system to the Lake Screen House was to reduce maintenance cost. This design change necessitated isolating the Circ Water Blowdown System on a daily basis to accommodate biocide injections into the Circ Water System, because our permits do not authorize discharge of biocide to the Kankakee River. When both units were in operation this was not an issue because partial blowdown flow was maintained from the unit not being chlorinated. The problem became apparent during outages when one unit was shut down. In this configuration, blowdown flow was stopped and started whenever the operating unit was chlorinated.
The daily requirement to isolate Circulating Water Blowdown for biocide injection, prompted the Operations Department to challenge the BwOP CW-12 procedural requirement to slowly open the motor operated valves for system start-up.
The daily requirement to isolate Circulating Water Blowdown for biocide injection, prompted the Operations Department to challenge the BwOP CW-12 procedural requirement to slowly open the motor operated valves for system start-up.
BwOP CW-12 was revised to allow fast motorized operation of motor operated valves, in lieu of slower manual throttling following short periods of system shutdown (i.e.: biocide injections).
BwOP CW-12 was revised to allow fast motorized operation of motor operated valves, in lieu of slower manual throttling following short periods of system shutdown (i.e.: biocide injections).
68
68 Page 4 of 6 Typical vacuum breaker:
 
AI R. RE LEASE VALVIE Ah%11 B lITTERLY VALVE 10 IFVI0 h4AL-CSIEE C"P34AW.V~
Attachment 6 Page 4 of 6 Typical vacuum breaker:
EWW)V:
AI R. RE LEASE VALVIE Ah%11 B lITTERLY VALVE 10 IFVI0 h4AL-CSIEE C"P34AW.V~ EWW)V:
~*~Efl.ata I.S.O MI.SScMJCWSC.,r Work history on the Circulating Water Blowdown System vacuum breakers was reviewed. There were no recorded vacuum breaker float assembly failures prior to 2000, however several instances of leaking air release valves were noted from the review. The VB-3 air release valve was discovered leaking in 12/98. PIF #
                  ~*~Efl.ata I.S.O MI.SScMJCWSC.,r Work history on the Circulating Water Blowdown System vacuum breakers was reviewed. There were no recorded vacuum breaker float assembly failures prior to 2000, however several instances of leaking air release valves were noted from the review. The VB-3 air release valve was discovered leaking in 12/98. PIF #
A1998-04324 was generated to address the flooding of site property and the Smiley Road ditch immediately adjacent to site property. The piping to the air release valve on the VB-1 failed in 12/96.
A1998-04324 was generated to address the flooding of site property and the Smiley Road ditch immediately adjacent to site property. The piping to the air release valve on the VB-1 failed in 12/96. The complete vacuum breaker assembly including air release valve was replaced with a new assembly in 1997.
The complete vacuum breaker assembly including air release valve was replaced with a new assembly in 1997.
It should be noted that the VB-1 vacuum breaker failed again on 11/20/2000. The float assembly broke at the bowl to guide bar weld. No other significant work history was identified.
It should be noted that the VB-1 vacuum breaker failed again on 11/20/2000. The float assembly broke at the bowl to guide bar weld.
No other significant work history was identified.
The failure of the VB-2 float assembly was discussed with the vendor. Based on the failure description, the vendor indicated that it appeared to be consistent with the effects of a pressure surge (i.e. water hammer). The vendor indicated that surge protection check valves should be considered for a vacuum breaker when pipe flows exceed 6 ft/s and are required when flow velocities exceed 10 ft/s.
The failure of the VB-2 float assembly was discussed with the vendor. Based on the failure description, the vendor indicated that it appeared to be consistent with the effects of a pressure surge (i.e. water hammer). The vendor indicated that surge protection check valves should be considered for a vacuum breaker when pipe flows exceed 6 ft/s and are required when flow velocities exceed 10 ft/s.
The vendor also recommended a 7-10 year PM frequency to address valve elastomer degradation. The condition was addressed by revising the operating procedure BwOP CW-12 to manually open and close the valves to slowly initiate or terminate blowdown flow.
The vendor also recommended a 7-10 year PM frequency to address valve elastomer degradation. The condition was addressed by revising the operating procedure BwOP CW-12 to manually open and close the valves to slowly initiate or terminate blowdown flow.
69
69 Page 5 of 6 The present circulating water blowdown system operates as follows. On system startup, the air/vacuum valve exhausts large amounts of air from the piping system until the float assembly in the air/vacuum valve rises with water level to close and seal during normal system operation.. To prevent the inrushing water from causing damage to the air/vacuum valve float, a surge check valve is installed just underneath the air/vacuum valve. The surge check is a spring loaded, normally open valve, which passes air through unrestricted. When water rushes into the check valve, the disc begins to close against the spring tension and reduces the flow rate of water into the air/vacuum valve by means of throttling holes in the disc. This ensures gentle closing of the air/vacuum valve float, regardless of initial flow velocity into the valve and minimizes pressure surges. Upon system shutdown, the vacuum valve is designed to open as water level decreases.
 
The air release valve provides two functions. The primary function is to release small amounts of entrained air that accumulates at the high points during normal system operation. If not removed, this air that would increase head loss and reduce process flow. The air release valve also facilitates earlier opening of the main air/vacuum valve on system shutdown. On shutdowns, air pockets that develop at high points may be at positive pressure, tending to hold the main air/vacuum float on its seat even though water level is below the float assembly. However, the air release valve will vent the air and allow the main air/vacuum valve to open as soon as water level drops. Each vacuum breaker is provided with a butterfly isolation valve to facilitate vacuum breaker maintenance.
Attachment 6 Page 5 of 6 The present circulating water blowdown system operates as follows. On system startup, the air/vacuum valve exhausts large amounts of air from the piping system until the float assembly in the air/vacuum valve rises with water level to close and seal during normal system operation.. To prevent the inrushing water from causing damage to the air/vacuum valve float, a surge check valve is installed just underneath the air/vacuum valve. The surge check is a spring loaded, normally open valve, which passes air through unrestricted. When water rushes into the check valve, the disc begins to close against the spring tension and reduces the flow rate of water into the air/vacuum valve by means of throttling holes in the disc. This ensures gentle closing of the air/vacuum valve float, regardless of initial flow velocity into the valve and minimizes pressure surges. Upon system shutdown, the vacuum valve is designed to open as water level decreases. The air release valve provides two functions. The primary function is to release small amounts of entrained air that accumulates at the high points during normal system operation. If not removed, this air that would increase head loss and reduce process flow. The air release valve also facilitates earlier opening of the main air/vacuum valve on system shutdown. On shutdowns, air pockets that develop at high points may be at positive pressure, tending to hold the main air/vacuum float on its seat even though water level is below the float assembly. However, the air release valve will vent the air and allow the main air/vacuum valve to open as soon as water level drops. Each vacuum breaker is provided with a butterfly isolation valve to facilitate vacuum breaker maintenance.
Modification of 2001-2003 changed the design of the air / vacuum valve assembly to a slow closing design with the use of a surge protector valve in-line.
Modification of 2001-2003 changed the design of the air / vacuum valve assembly to a slow closing design with the use of a surge protector valve in-line.
This modification protects the air/vacuum valves from pressure surges experienced during water hammer events.
This modification protects the air/vacuum valves from pressure surges experienced during water hammer events.
Modification of 2003 installed CW Blowdown Booster Pumps to increase the blowdown flow rate to 25,000 gpm for improving lake chemistry. With increased flow rates during booster pump operation the volume of voided blowdown line may decrease, closing previously open air / vacuum valves under lower flow conditions. Start up and shut down procedures for the booster pumps specify flow / pump increase / decrease ramp rates to minimize potential column separation water hammer pressure surges.
Modification of 2003 installed CW Blowdown Booster Pumps to increase the blowdown flow rate to 25,000 gpm for improving lake chemistry. With increased flow rates during booster pump operation the volume of voided blowdown line may decrease, closing previously open air / vacuum valves under lower flow conditions. Start up and shut down procedures for the booster pumps specify flow / pump increase / decrease ramp rates to minimize potential column separation water hammer pressure surges.
70
70 Page 6 of 6 Modification of 2005 installed a de-chlorination modification to allow continuous operation of the Blowdown System while performing unit chlorination. This modification allowed blowdown to be in-service essentially all the time, reducing the potential for air / vacuum valves leaks caused by system flow rate changes.
 
Attachment 6 Page 6 of 6 Modification of 2005 installed a de-chlorination modification to allow continuous operation of the Blowdown System while performing unit chlorination. This modification allowed blowdown to be in-service essentially all the time, reducing the potential for air / vacuum valves leaks caused by system flow rate changes.
The aggregate impact of the three modifications was to assure nearly continuous operation of the blowdown system which minimizes the inclusion of air and the possibility of damaging water hammer at the vacuum breaker valves.
The aggregate impact of the three modifications was to assure nearly continuous operation of the blowdown system which minimizes the inclusion of air and the possibility of damaging water hammer at the vacuum breaker valves.
71
71


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Attachment 8 Review of Exelon Hazmat Spill Response Procedures Page 1 of 3 In general, there is no spill response procedure, which would acknowledge the subsurface water transport mechanism from onsite to offsite locations. The three documents reviewed were a draft procedure circulated in 10/16/90, "General Action Plan for Response to Unmonitored Releases and Very Low Level Radioactive Spills", BwAP 750-4, "Hazardous Material Spill Response", and BwAP 1100-16, "Fire/Hazardous Materials Spill and/or Injury Response", and NSP-RP-6101, "10 CFR 50.75(g)(1) Documentation Requirements".
NTnrth Godley Illinois Braidwood Station Kankakee River 75 Review of Exelon Hazmat Spill Response Procedures Page 1 of 3 In general, there is no spill response procedure, which would acknowledge the subsurface water transport mechanism from onsite to offsite locations. The three documents reviewed were a draft procedure circulated in 10/16/90, "General Action Plan for Response to Unmonitored Releases and Very Low Level Radioactive Spills", BwAP 750-4, "Hazardous Material Spill Response", and BwAP 1100-16, "Fire/Hazardous Materials Spill and/or Injury Response", and NSP-RP-6101, "10 CFR 50.75(g)(1) Documentation Requirements".
The most significant barrier deficiencies noted was that the 1990 draft procedure may have prompted reviewing hydrology and dose to the public from radiological contamination of groundwater. Additionally, the procedure to document the spill for 10 CFR 50.75(g)(1) requirements for decommissioning prompts to perform a potential dose impact to the public from the spill, but does not require any specific pathway (i.e. subsurface migration of contaminants to drinking water).
The most significant barrier deficiencies noted was that the 1990 draft procedure may have prompted reviewing hydrology and dose to the public from radiological contamination of groundwater.
Procedure                                   Relevant Content                             Barrier Analysis Draft Procedure CSG-001,     The draft procedure contained pertinent information about:           Missed opportunity to "General Action Plan for
Additionally, the procedure to document the spill for 10 CFR 50.75(g)(1) requirements for decommissioning prompts to perform a potential dose impact to the public from the spill, but does not require any specific pathway (i.e. subsurface migration of contaminants to drinking water).
* For situations involving subsurface contamination,           erect a barrier.
Procedure Relevant Content Barrier Analysis Draft Procedure CSG-001, The draft procedure contained pertinent information about:
Response to Unmonitored               corrective action may mean the preparation of a Releases and Very Low Level           submittal pursuant to the I1Adm. Code 340.3020 and 10       This procedure may have Radioactive Spills"                   CFR 20.302 requesting the in-place disposal of             prompted recognition of subsurface contamination,                                   dose impacts from the Circulated as a Draft
Missed opportunity to "General Action Plan for For situations involving subsurface contamination, erect a barrier.
* Environment - refers to any surface water, groundwater,       contamination of procedure 10/16/90. No                 sanitary or storm sewers, soil, land surface, or subsurface groundwater and record of this becoming an             strata and vegetation,                                     supporting hydrology actual procedure.
Response to Unmonitored corrective action may mean the preparation of a Releases and Very Low Level submittal pursuant to the I1 Adm. Code 340.3020 and 10 This procedure may have Radioactive Spills" CFR 20.302 requesting the in-place disposal of prompted recognition of subsurface contamination, dose impacts from the Circulated as a Draft Environment - refers to any surface water, groundwater, contamination of procedure 10/16/90. No sanitary or storm sewers, soil, land surface, or subsurface groundwater and record of this becoming an strata and vegetation, supporting hydrology actual procedure.
* Subsurface contamination and hydrology 'concerns           issues.
Subsurface contamination and hydrology 'concerns issues.
0 Reviewing to ensure the spill is not in excess of This procedure contains               Reportable Quantity quantities in 40 CFR 302 App B or       May have provided an information relevant to the           40 CFR 355 App A                                             opportunity for all former underground water dose           0 Required evaluation of exposure pathways from                 CornEd nuclear plants to pathway to the public now             infiltration and contamination of groundwater.               recognize the potential being evaluated. Not                                                                               issue.
0 Reviewing to ensure the spill is not in excess of This procedure contains Reportable Quantity quantities in 40 CFR 302 App B or May have provided an information relevant to the 40 CFR 355 App A opportunity for all former underground water dose 0
implementing this procedure was a missed opportunity to erect a barrier to recognize Page 2 of 3 BwAP 750-4, "Hazardous       In general, site personnel would not consider entry into the         Minor missed barrier.
Required evaluation of exposure pathways from CornEd nuclear plants to pathway to the public now infiltration and contamination of groundwater.
Material Spill Response"     hazmat spill procedure for a water spill.
recognize the potential being evaluated. Not issue.
The procedure contains the following pertinent information:           Missing this barrier was
implementing this procedure was a missed opportunity to erect a barrier to recognize Page 2 of 3 BwAP 750-4, "Hazardous In general, site personnel would not consider entry into the Minor missed barrier.
* The procedure references Hazardous Materials as listed in         of no consequence. The 40 CFR 302.4, which lists many chemicals, but not           RP organization did not 76
Material Spill Response" hazmat spill procedure for a water spill.
The procedure contains the following pertinent information:
Missing this barrier was The procedure references Hazardous Materials as listed in of no consequence. The 40 CFR 302.4, which lists many chemicals, but not RP organization did not 76


Procedure                                     Relevant Content                             Barrier Analysis radioactive material. The intent of this reference is to   have subsequent ensure that a "Reportable Quantity" has not been spilled   proceduresto respond to on the ground. The absence of radioactive materials         the subsurface transport from the list in the procedure does not preclude someone   issues, which are of issue from looking for radioactive material in 40 CFR 302.4,     today.
Procedure Relevant Content Barrier Analysis radioactive material. The intent of this reference is to have subsequent ensure that a "Reportable Quantity" has not been spilled proceduresto respond to on the ground. The absence of radioactive materials the subsurface transport from the list in the procedure does not preclude someone issues, which are of issue from looking for radioactive material in 40 CFR 302.4, today.
but the procedure does not offer a clear barrier to trip recognition of a radioactive material spill as a hazmat event per this procedure. Even if radioactive materials was clearly on the Reportable Quantity list, the RP organization does not have a procedure documenting additional required actions.
but the procedure does not offer a clear barrier to trip recognition of a radioactive material spill as a hazmat event per this procedure. Even if radioactive materials was clearly on the Reportable Quantity list, the RP organization does not have a procedure documenting additional required actions.
The procedure states, "Spills containing radiologically contaminated material shall be reported to the Radiation Protection Dept.
The procedure states, "Spills containing radiologically contaminated material shall be reported to the Radiation Protection Dept.
BwAP 1100-16,                 The hazmat procedure does not contain information to specify         Minor missed barrier.
BwAP 1100-16, The hazmat procedure does not contain information to specify Minor missed barrier.
"Fire/Hazardous Materials     actions that might direct specific radiological actions to minimize Spill and/or Injury Response" the significance of a similar event. The procedure essentially       Missing this barrier was defers radiological spills to the RP organization. The procedure     of no consequence. The contains the following radiological information:                     RP organization did not Notify Rad Protection to dispatch personnel to the         have subsequent fire/spill area for radiation detection and first aid       procedures to respond to purposes.                                                   the subsurface transport issues, which are of issue today.
"Fire/Hazardous Materials actions that might direct specific radiological actions to minimize Spill and/or Injury Response" the significance of a similar event. The procedure essentially Missing this barrier was defers radiological spills to the RP organization. The procedure of no consequence. The contains the following radiological information:
Page 3 of 3 NSP-RP-6 101, "10 CFR         This procedure is intended to provide the following information      Missed barrier 50.75(g)(1) Documentation     as required from the regulation:
RP organization did not Notify Rad Protection to dispatch personnel to the have subsequent fire/spill area for radiation detection and first aid procedures to respond to purposes.
Requirements"
the subsurface transport issues, which are of issue today.
* 10 CFR 50.75(g)(1) Records of spills or other unusual         The procedure requires an occurrences involving the spread of contamination in         assessment of potential and around the facility, equipment, or site. These records dose to the public from may be limited to instances when significant               the remaining radioactive contamination remains after any cleanup procedures or       material, but does not when there is reasonable likelihood that contaminants       prompt for the pathway of may have spread to inaccessible areas as in the case of     subsurface migration possible seepage into porous materials such as concrete. through groundwater to These records must include any known information on         drinking water.
Page 3 of 3 NSP-RP-6 101, "10 CFR 50.75(g)(1) Documentation Requirements" This procedure is intended to provide the following information as required from the regulation:
identification of involved nuclides, quantities, forms, and concentrations.
10 CFR 50.75(g)(1) Records of spills or other unusual occurrences involving the spread of contamination in and around the facility, equipment, or site. These records may be limited to instances when significant contamination remains after any cleanup procedures or when there is reasonable likelihood that contaminants may have spread to inaccessible areas as in the case of possible seepage into porous materials such as concrete.
* The actual procedure requires addressing:
These records must include any known information on identification of involved nuclides, quantities, forms, and concentrations.
o Concentrations of involved radionuclides o Quantities of material(s) o Forms of material(s), (e.g. solubility and permeability of the contaminant) o Description of the event o Impact of the remaining radioactive material on the health and safety of the public o Affected areas
The actual procedure requires addressing:
* The procedure prompts to perform a potential dose impact to members of the public, but it does not describe pathways to be analyzed (i.e. subsurface migration of contaminants to drinking water). The general absence of tools to calculate the specifics of subsurface transport mechanisms may have prompted actual measurements through the drilling of wells to sample water or sample existing offsite wells. Corrective Action (CA-2 1) addresses performing a dose assessment to determine the dose impact to the public from radiological spills by including this action in the 10 CFR 50.75(g)(1) procedure. The purpose of corrective action 21 is to link 77
o Concentrations of involved radionuclides o
Quantities of material(s) o Forms of material(s), (e.g. solubility and permeability of the contaminant) o Description of the event o
Impact of the remaining radioactive material on the health and safety of the public o
Affected areas The procedure prompts to perform a potential dose impact to members of the public, but it does not describe pathways to be analyzed (i.e. subsurface migration of contaminants to drinking water). The general absence of tools to calculate the specifics of subsurface transport mechanisms may have prompted actual measurements through the drilling of wells to sample water or sample existing offsite wells. Corrective Action (CA-2 1) addresses performing a dose assessment to determine the dose impact to the public from radiological spills by including this action in the 10 CFR 50.75(g)(1) procedure. The purpose of corrective action 21 is to link Missed barrier The procedure requires an assessment of potential dose to the public from the remaining radioactive material, but does not prompt for the pathway of subsurface migration through groundwater to drinking water.
77


Procedure             Relevant Content                     Barrier Analysis the 10CFR 50.75(g) with the ODCM for tracking the impact on dose of isotopics in groundwater.
Procedure Relevant Content Barrier Analysis the 10CFR 50.75(g) with the ODCM for tracking the impact on dose of isotopics in groundwater.
78
78 Reportability Manual Review - LS-AA-1 020 and LS-AA-1 110 Page 1 of 3 Various documents were reviewed by this Root Cause Investigation Team to determine the expected reporting requirements for an event such as discovering radiologically contaminated water leaking from a plant system onto the ground within the owner-controlled area.
 
Attachment 9 Reportability Manual Review - LS-AA-1 020 and LS-AA-1 110 Page 1 of 3 Various documents were reviewed by this Root Cause Investigation Team to determine the expected reporting requirements for an event such as discovering radiologically contaminated water leaking from a plant system onto the ground within the owner-controlled area.
LS-AA-1020 Radiological Decision Tree was reviewed. The Liquid Release or Spill portion of the tree references SAF 1.9, News Release or Notification of Other Government Agency. SAF 1.9 requires NRC notification for any event related to the health and safety of the public or onsite personnel, or protection of the environment requiring a news release or notification of another government agency. One example described is the unplanned release of radioactively contaminated materials. Since the vacuum breaker leaks (spills) were contained onsite, the leak would not be characterized as a release per the Offsite Dose Calculation Manual.
LS-AA-1020 Radiological Decision Tree was reviewed. The Liquid Release or Spill portion of the tree references SAF 1.9, News Release or Notification of Other Government Agency. SAF 1.9 requires NRC notification for any event related to the health and safety of the public or onsite personnel, or protection of the environment requiring a news release or notification of another government agency. One example described is the unplanned release of radioactively contaminated materials. Since the vacuum breaker leaks (spills) were contained onsite, the leak would not be characterized as a release per the Offsite Dose Calculation Manual.
Since the leak was onsite, there was no perceived health or safety risk to the public. A review of several Incident Reports (IR's) indicates that these leaks were not considered a public risk since the leaks were onsite. These IR's also reasonably concluded that National Pollution Discharge Elimination System (NPDES) violations did not occur and therefore, Environmental Protection Agency (EPA) notification was not required. Based on the nature of the leak, there was no safety or health risk to onsite personnel. Therefore, it was reasonable to conclude that these events were not reportable per SAF 1.9.
Since the leak was onsite, there was no perceived health or safety risk to the public. A review of several Incident Reports (IR's) indicates that these leaks were not considered a public risk since the leaks were onsite. These IR's also reasonably concluded that National Pollution Discharge Elimination System (NPDES) violations did not occur and therefore, Environmental Protection Agency (EPA) notification was not required. Based on the nature of the leak, there was no safety or health risk to onsite personnel. Therefore, it was reasonable to conclude that these events were not reportable per SAF 1.9.
The Liquid Release or Spill portion of the Radiological Decision Tree also references RAD 1.1, Events Involving Byproduct, Source or Special Nuclear Material that Cause or Threaten to Cause Significant Exposure or Release. One of the reporting requirements concerns the release of radioactive material inside or outside the restricted area, but is not reportable if the location is not normally stationed during routine operations. Since personnel would not normally be stationed at the vacuum breakers, reporting was not required.
The Liquid Release or Spill portion of the Radiological Decision Tree also references RAD 1.1, Events Involving Byproduct, Source or Special Nuclear Material that Cause or Threaten to Cause Significant Exposure or Release.
One of the reporting requirements concerns the release of radioactive material inside or outside the restricted area, but is not reportable if the location is not normally stationed during routine operations. Since personnel would not normally be stationed at the vacuum breakers, reporting was not required.
RAD 1.4, Liquid Effluent Release requires reporting when radioactive material is present at levels greater than 10 times applicable limits. The piping leaks were within the restricted areas and therefore were not considered an effluent release. Migration of contaminated groundwater offsite should be considered an effluent release, but was not considered. To date, measurable tritium concentrations in groundwater offsite are within 10 times the applicable limits. The event is not reportable per RAD 1.4.
RAD 1.4, Liquid Effluent Release requires reporting when radioactive material is present at levels greater than 10 times applicable limits. The piping leaks were within the restricted areas and therefore were not considered an effluent release. Migration of contaminated groundwater offsite should be considered an effluent release, but was not considered. To date, measurable tritium concentrations in groundwater offsite are within 10 times the applicable limits. The event is not reportable per RAD 1.4.
RAD 1.8, Effluent Release was not considered applicable since a release normally occurs at the authorized or intended discharge point. Therefore, reportability per RAD 1.8 was not considered. Offsite release via groundwater was not considered. Based on the measured tritium results off site, the requirements described in RAD .1.8 have not been exceeded and therefore, reportability per RAD 1.8 is not required.
RAD 1.8, Effluent Release was not considered applicable since a release normally occurs at the authorized or intended discharge point.
79
Therefore, reportability per RAD 1.8 was not considered.
 
Offsite release via groundwater was not considered.
Attachment 9.
Based on the measured tritium results off site, the requirements described in RAD.1.8 have not been exceeded and therefore, reportability per RAD 1.8 is not required.
Reportability Manual Review - LS-AA-1 020 and LS-AA-1110 Page 2 of 3 RAD 1.21, Release of Radionuclides, requires reporting when the limits of 40 CFR 302 are-exceeded. For tritium, the 40 CFR 302 limit is 100 Curies released within a 24-hour period.
79 Reportability Manual Review - LS-AA-1 020 and LS-AA-1110 Page 2 of 3 RAD 1.21, Release of Radionuclides, requires reporting when the limits of 40 CFR 302 are-exceeded. For tritium, the 40 CFR 302 limit is 100 Curies released within a 24-hour period.
Review of effluent release data indicates that the 100-curie limit was not challenged during radioactive releases over the vacuum breaker leakage timeframe. Therefore, reportability per RAD 1.21 was not required.
Review of effluent release data indicates that the 100-curie limit was not challenged during radioactive releases over the vacuum breaker leakage timeframe. Therefore, reportability per RAD 1.21 was not required.
RAD 1.22, Release of Hazardous Substances-(including radionuclides) is not applicable based on the RAD 1.21 discussion.
RAD 1.22, Release of Hazardous Substances-(including radionuclides) is not applicable based on the RAD 1.21 discussion.
The other sections of the Liquid Release or Spill portion of the Radiological Decision Tree do not apply.
The other sections of the Liquid Release or Spill portion of the Radiological Decision Tree do not apply.
The other sections of the Radiological Decision Tree were reviewed and do not apply.
The other sections of the Radiological Decision Tree were reviewed and do not apply.
LS-AA-1020 Environmental decision tree was also reviewed. The Other Significant Event section was reviewed. ENV 3.26 Unusual or Important Environmental Events requires reporting of any event that did or could have significant environmental impact. It is reasonable that a blowdown water spill onsite would not have a significant environmental impact and therefore notification would not be made. However, potential groundwater contamination and migration to public wells was not considered.
LS-AA-1020 Environmental decision tree was also reviewed.
The Other Significant Event section was reviewed. ENV 3.26 Unusual or Important Environmental Events requires reporting of any event that did or could have significant environmental impact. It is reasonable that a blowdown water spill onsite would not have a significant environmental impact and therefore notification would not be made. However, potential groundwater contamination and migration to public wells was not considered.
The other sections of the Environmental Decision Tree were reviewed and would not apply.
The other sections of the Environmental Decision Tree were reviewed and would not apply.
40 CFR 141.16 states that the average annual tritium concentration shall not exceed 20,000 pCi/L in a community drinking water system. A community drinking water system is defined in the regulation as a public water system that serves at least 15 year round residents. The reportability manual appropriately references 40 CFR 141.
40 CFR 141.16 states that the average annual tritium concentration shall not exceed 20,000 pCi/L in a community drinking water system. A community drinking water system is defined in the regulation as a public water system that serves at least 15 year round residents. The reportability manual appropriately references 40 CFR 141.
35 IAC 620 has the same 20,000 pCi/L limit and definition of community drinking water system as described in 40 CFR 141.16. However, 35 IAC 620 does not limit the tritium concentration to community drinking water. This Illinois standard limits tritium concentration in "Class I: Potable Resource Water," which is defined, in part, as water located 10 feet or more below the surface that is capable of potable use. Per discussion with Conestoga-Rovers & Associates and the Exelon Hydrologist, onsite groundwater at Braidwood station is classified as Class I: Potable Resource Water in accordance with 35 IAC 620. Therefore, any tritium leakage into the groundwater onsite could exceed the requirements of 35 IAC 620.
35 IAC 620 has the same 20,000 pCi/L limit and definition of community drinking water system as described in 40 CFR 141.16. However, 35 IAC 620 does not limit the tritium concentration to community drinking water. This Illinois standard limits tritium concentration in "Class I: Potable Resource Water," which is defined, in part, as water located 10 feet or more below the surface that is capable of potable use. Per discussion with Conestoga-Rovers & Associates and the Exelon Hydrologist, onsite groundwater at Braidwood station is classified as Class I: Potable Resource Water in accordance with 35 IAC 620.
Therefore, any tritium leakage into the groundwater onsite could exceed the requirements of 35 IAC 620.
The reporting requirements for the Radiological Environmental Monitoring Program (REMP) are specified in the Braidwood ODCM, section 12.5.1. Table 12.5-2 lists REMP reporting levels for tritium and other radionuclides that are monitored in various types of samples obtained. These ODCM required reporting requirements are not listed in the Reportability Manual. Groundwater samples indicate that the reporting level of tritium per Table 12.5-2 have been exceeded.
The reporting requirements for the Radiological Environmental Monitoring Program (REMP) are specified in the Braidwood ODCM, section 12.5.1. Table 12.5-2 lists REMP reporting levels for tritium and other radionuclides that are monitored in various types of samples obtained. These ODCM required reporting requirements are not listed in the Reportability Manual. Groundwater samples indicate that the reporting level of tritium per Table 12.5-2 have been exceeded.
80
80 Reportability Manual Review-LS-AA-1020 and LS-AA-1110 Page 3 of 3 The Braidwood ODCM REMP drinking water tritium concentration reporting requirements are consistent with the requirements of 40 CFR 141 and 35 IAC 620. However, per ODCM Section 12.5.1, reportability is based on a quarterly average. 40 CFR 141 and 35 IAC 620 reportability are based on an annual average - the ODCM reportability is conservative and consistent with the recommendations in NUREG 1301 Section 3.12.1.
 
Attachment 9 Reportability Manual Review- LS-AA-1020 and LS-AA-1110 Page 3 of 3 The Braidwood ODCM REMP drinking water tritium concentration reporting requirements are consistent with the requirements of 40 CFR 141 and 35 IAC 620. However, per ODCM Section 12.5.1, reportability is based on a quarterly average. 40 CFR 141 and 35 IAC 620 reportability are based on an annual average - the ODCM reportability is conservative and consistent with the recommendations in NUREG 1301 Section 3.12.1.
There is no mention of 35 IAC 611 or 35 IAC 620 requirements in the Braidwood ODCM (CA4).
There is no mention of 35 IAC 611 or 35 IAC 620 requirements in the Braidwood ODCM (CA4).
The Reportability Manual was reviewed for references to the various drinking water and groundwater standards. There is appropriate reference to 40 CFR 141 and 35 IAC 611.
The Reportability Manual was reviewed for references to the various drinking water and groundwater standards.
There is appropriate reference to 40 CFR 141 and 35 IAC 611.
However, there were not sufficient references to 35 IAC 620. Based on this review, there was inadequate knowledge of the requirements of 35 IAC 620 and the transport of radioactivity offsite via the groundwater pathway.
However, there were not sufficient references to 35 IAC 620. Based on this review, there was inadequate knowledge of the requirements of 35 IAC 620 and the transport of radioactivity offsite via the groundwater pathway.
In 2005, Illinois passed SB241, which became effective on July 25, 2005. This legislation states that if the Illinois Environmental Protection Agency (IEPA) makes a determination that groundwater poses a threat of exposure above Class I groundwater standards (35 IAC 620),
In 2005, Illinois passed SB241, which became effective on July 25, 2005. This legislation states that if the Illinois Environmental Protection Agency (IEPA) makes a determination that groundwater poses a threat of exposure above Class I groundwater standards (35 IAC 620),
then public notification is required. The IEPA does not require conclusive evidence of exceeding a standard. The notification can be based on modeling that demonstrates a trend towards exceeding a standard.
then public notification is required.
The IEPA does not require conclusive evidence of exceeding a standard. The notification can be based on modeling that demonstrates a trend towards exceeding a standard.
While this legislation does not require site reporting and does not change daily operation, it does impact the site because public notification can be made based on groundwater contaminant concentrations that are below reportable thresholds. There is no mechanism in place for site technical expertise to be made aware of new legislation such as Illinois SB241 (CA8).
While this legislation does not require site reporting and does not change daily operation, it does impact the site because public notification can be made based on groundwater contaminant concentrations that are below reportable thresholds. There is no mechanism in place for site technical expertise to be made aware of new legislation such as Illinois SB241 (CA8).
References Braidwood Offsite Dose Calculation Manual LS-AA-1020, Reportability Reference Manual, Revision 8 LS-AA-1 110, Reportable Event SAF, Revision 6 LS-AA-1 120, Reportable Event Radiation (RAD), Revision 3 LS-MW-1 310, Reportable Event SAF, Revision 3 LS-MW-1 340, Reportable Event, ENV, Revision 4 LS-AA-1400, Event Reporting Guidelines, Revision 2 LS-MW-1340, Reportable Events, ENV, Revision 4 40 CFR 302, Designation, Reportable Quantities, and Notification 40 CFR 141, National Primary Drinking Water Regulations 35 IAC 611, Primary Drinking Water Standards 35 IAC 620, Groundwater Quality 81
References Braidwood Offsite Dose Calculation Manual LS-AA-1020, Reportability Reference Manual, Revision 8 LS-AA-1 110, Reportable Event SAF, Revision 6 LS-AA-1 120, Reportable Event Radiation (RAD), Revision 3 LS-MW-1 310, Reportable Event SAF, Revision 3 LS-MW-1 340, Reportable Event, ENV, Revision 4 LS-AA-1400, Event Reporting Guidelines, Revision 2 LS-MW-1340, Reportable Events, ENV, Revision 4 40 CFR 302, Designation, Reportable Quantities, and Notification 40 CFR 141, National Primary Drinking Water Regulations 35 IAC 611, Primary Drinking Water Standards 35 IAC 620, Groundwater Quality 81 0
 
Page 1 of 14 Summary of Applicable State, Federal, and Offsite Dose Calculation Manual (ODCM) Regulations and Requirements for Tritium Releases to the Environment TITLE 35: ENVIRONMENTAL PROTECTION SUBTITLE F: PUBLIC WATER SUPPLIES CHAPTER I: POLLUTION CONTROL BOARD PART 620.410 GROUNDWATER QUALITY Effective November 25, 1991Class I: Potable Groundwater e) Beta Particle and Photon Radioactivity
Attachment 10 Page 1 of 14 Summary of Applicable State, Federal, and Offsite Dose Calculation Manual (ODCM) Regulations and Requirements for Tritium Releases to the Environment TITLE 35: ENVIRONMENTAL PROTECTION SUBTITLE F: PUBLIC WATER SUPPLIES CHAPTER I: POLLUTION CONTROL BOARD PART 620.410 GROUNDWATER QUALITY Effective November 25, 1991Class I: Potable Groundwater e) Beta Particle and Photon Radioactivity
: 1) Except due to natural causes, the average annual concentration of beta particle and photon radioactivity from man-made radionuclides shall not exceed a dose equivalent to the total body organ greater than 4 norem/year in Class I groundwater. If two or more radionuclides are present, the sum of their dose equivalent to the total body, or to any internal organ shall not exceed 4 mrem/year in Class I groundwater except due to natural causes.
: 1) Except due to natural causes, the average annual concentration of beta particle and photon radioactivity from man-made radionuclides shall not exceed a dose equivalent to the total body organ greater than 4 norem/year in Class I groundwater. If two or more radionuclides are present, the sum of their dose equivalent to the total body, or to any internal organ shall not exceed 4 mrem/year in Class I groundwater except due to natural causes.
: 2) Except for the radionuclides listed in subsection (e)(3), the concentration of man-made radionuclides causing 4 mrem total body or organ dose equivalent must be calculated on the basis of a 2 liter per day drinking water intake using the 168-hour data in accordance with the procedure set forth in NCRP Report Number 22, incorporated by reference in Section 620.125(a).
: 2) Except for the radionuclides listed in subsection (e)(3), the concentration of man-made radionuclides causing 4 mrem total body or organ dose equivalent must be calculated on the basis of a 2 liter per day drinking water intake using the 168-hour data in accordance with the procedure set forth in NCRP Report Number 22, incorporated by reference in Section 620.125(a).
: 3) Except due to natural causes, the average annual concentration assumed to produce a total body or organ dose of 4 mrem/year of the following chemical constituents shall not be exceeded in Class I groundwater:
: 3) Except due to natural causes, the average annual concentration assumed to produce a total body or organ dose of 4 mrem/year of the following chemical constituents shall not be exceeded in Class I groundwater:
Critical Standard Constituent             Organ                   (pCi/L)
Critical Standard Constituent Organ (pCi/L)
Tritium                 Total body             20,000.0 Strontium-90           Bone marrow             8.0 82
Tritium Total body 20,000.0 Strontium-90 Bone marrow 8.0 82 0
 
Page 2 of 14 ODCM Appendix A Revision 3 January 2002 A.2.2 Liquid Effluent Concentrations Requirement Requirement One method of demonstrating compliance to the requirements of 10 CFR 20.1301 is to demonstrate that the annual average concentrations of radioactive material released in gaseous and liquid effluents do not exceed the values specified in 10 CFR 20 Appendix B, Table 2, Column 2. (See 10 CFR 20.1302(b)(2).)
Attachment 10 Page 2 of 14 ODCM Appendix A Revision 3 January 2002 A.2.2 Liquid Effluent Concentrations Requirement Requirement One method of demonstrating compliance to the requirements of 10 CFR 20.1301 is to demonstrate that the annual average concentrations of radioactive material released in gaseous and liquid effluents do not exceed the values specified in 10 CFR 20 Appendix B, Table 2, Column 2. (See 10 CFR 20.1302(b)(2).)
However, as noted in Section A.5.1, this mode of 10 CFR 20.1301 compliance has not been elected.
However, as noted in Section A.5.1, this mode of 10 CFR 20.1301 compliance has not been elected.
[Mode of compliance selected is as follows:]
[Mode of compliance selected is as follows:]
Line 825: Line 1,146:
A.2.4 Tank Overflow Requirement To limit the consequences of tank overflow, the RETS/Technical Specifications may limit the quantity of radioactivity that may be stored in unprotected outdoor tanks. Unprotected tanks are tanks that are not surrounded by liners, dikes, or walls capable of holding the tank contents and that do not have tank overflows and surrounding area drains connected to the liquid radwaste treatment system. The specific objective is to provide assurance that in the event of an uncontrolled release of a tank's contents, the resulting radioactivity concentrations beyond the unrestricted area boundary, at the nearest potable water supply and at the nearest surface water supply, will be less than the limits of 10 CFR 20 Appendix B, Table 2; Column 2.
A.2.4 Tank Overflow Requirement To limit the consequences of tank overflow, the RETS/Technical Specifications may limit the quantity of radioactivity that may be stored in unprotected outdoor tanks. Unprotected tanks are tanks that are not surrounded by liners, dikes, or walls capable of holding the tank contents and that do not have tank overflows and surrounding area drains connected to the liquid radwaste treatment system. The specific objective is to provide assurance that in the event of an uncontrolled release of a tank's contents, the resulting radioactivity concentrations beyond the unrestricted area boundary, at the nearest potable water supply and at the nearest surface water supply, will be less than the limits of 10 CFR 20 Appendix B, Table 2; Column 2.
The Technical Specifications and RETS may contain a somewhat similar provision. For most nuclear power stations, specific numerical limits are specified on the number of curies allowed in affected tanks.
The Technical Specifications and RETS may contain a somewhat similar provision. For most nuclear power stations, specific numerical limits are specified on the number of curies allowed in affected tanks.
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Page 3 of 14 A.2.5 Operability and Use of the Liquid Radwaste Treatment System Requirement The design objectives of 10 CFR 50, Appendix I and RETS/Technical Specifications require that the liquid radwaste treatment system be operable and that appropriate portions be used to reduce releases of radioactivity when projected doses due to the liquid effluent from each reactor unit to restricted area boundaries exceed either of the following (see Section 12.3 of each station's RETS or Technical Specifications);
Attachment 10 Page 3 of 14 A.2.5 Operability and Use of the Liquid Radwaste Treatment System Requirement The design objectives of 10 CFR 50, Appendix I and RETS/Technical Specifications require that the liquid radwaste treatment system be operable and that appropriate portions be used to reduce releases of radioactivity when projected doses due to the liquid effluent from each reactor unit to restricted area boundaries exceed either of the following (see Section 12.3 of each station's RETS or Technical Specifications);
* 0.06 mrem to the total body in a 31 day period.
* 0.06 mrem to the total body in a 31 day period.
* 0.2 mrem to any organ in a 31 day period.
* 0.2 mrem to any organ in a 31 day period.
A.2.6 Drinking Water Five nuclear power stations (Braidwood, Dresden, LaSalle, Quad Cities, and Zion) have requirements for calculation of drinking water dose that are related to 40 CFR 141, the Environmental Protection Agency National Primary Drinking Water Regulations. These are discussed in Section A.6.
A.2.6 Drinking Water Five nuclear power stations (Braidwood, Dresden, LaSalle, Quad Cities, and Zion) have requirements for calculation of drinking water dose that are related to 40 CFR 141, the Environmental Protection Agency National Primary Drinking Water Regulations. These are discussed in Section A.6.
A.6     DOSE DUE TO DRINKING WATER (40 CFR 141)
A.6 DOSE DUE TO DRINKING WATER (40 CFR 141)
The National Primary Drinking Water Regulations, 40 CFR 141, contain the requirements of the Environmental Protection Agency applicable to public water systems. Included are limits on radioactivity concentration. Although these regulations are directed at the owners and operators of public water systems, several stations have requirements in their Technical Specifications related to 40 CFR 141.
The National Primary Drinking Water Regulations, 40 CFR 141, contain the requirements of the Environmental Protection Agency applicable to public water systems. Included are limits on radioactivity concentration. Although these regulations are directed at the owners and operators of public water systems, several stations have requirements in their Technical Specifications related to 40 CFR 141.
A.6.1 40 CFR 141 Restrictions on Manmade Radionuclides Section 141.16 states the following (not verbatim):
A.6.1 40 CFR 141 Restrictions on Manmade Radionuclides Section 141.16 states the following (not verbatim):
(a)   The average annual concentration of beta particle and photon radioactivity from man-made radionuclides in drinking water shall not produce an annual dose equivalent to the total body or any internal organ greater than 4 millirem/year.
(a)
(b)     Except for the radionuclides listed in Table A-0, the concentration of man-made radionuclides causing 4 mrem total body or organ dose equivalents shall be calculated on the basis of drinking 2 liter of water per day. (Using the 168 hour data listed in "Maximum Permissible Body Burdens and Maximum Permissible Concentration of Radionuclides in Air or Water for Occupational Exposure, "NBS Handbook 69 as amended August 1963, U.S. Department of Commerce.). If two or more radionuclides are present, the sum of their annual dose equivalents to the total body or any organ shall not exceed 4 milliremlyear.
The average annual concentration of beta particle and photon radioactivity from man-made radionuclides in drinking water shall not produce an annual dose equivalent to the total body or any internal organ greater than 4 millirem/year.
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(b)
 
Except for the radionuclides listed in Table A-0, the concentration of man-made radionuclides causing 4 mrem total body or organ dose equivalents shall be calculated on the basis of drinking 2 liter of water per day. (Using the 168 hour data listed in "Maximum Permissible Body Burdens and Maximum Permissible Concentration of Radionuclides in Air or Water for Occupational Exposure, "NBS Handbook 69 as amended August 1963, U.S. Department of Commerce.). If two or more radionuclides are present, the sum of their annual dose equivalents to the total body or any organ shall not exceed 4 milliremlyear.
Attachment 10 Page 4 of 14 TABLE A-0 AVERAGE ANNUAL CONCENTRATIONS ASSUMED TO PRODUCE A TOTAL BODY OR ORGAN DOSE OF 4 MREM/YR Radionuclide         Critical Organ         pCi / liter Tritium               Total body           20,000 Strontium-90           Bone marrow               8 LIQUID EFFLUENTS Chapter 12 Revision 7 September, 2002 12.3.1 Concentration Operability Requirements 12.3.1.A       The concentration of radioactive material released in liquid effluents to UNRESTRICTED AREAS (see Braidwood Station ODCM Annex, Appendix F, Figure F-i) shall be limited to 10 times the concentration values in Appendix B, Table 2, Column 2 to 10 CFR 20.1001-20.2402, for radionuclides other than dissolved or entrained noble gases. For dissolved or entrained noble gases, the concentration shall be limited to 2x10-4 microCurie/mI total activity.
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Page 4 of 14 TABLE A-0 AVERAGE ANNUAL CONCENTRATIONS ASSUMED TO PRODUCE A TOTAL BODY OR ORGAN DOSE OF 4 MREM/YR Radionuclide Critical Organ pCi / liter Tritium Total body 20,000 Strontium-90 Bone marrow 8
LIQUID EFFLUENTS Chapter 12 Revision 7 September, 2002 12.3.1 Concentration Operability Requirements 12.3.1.A The concentration of radioactive material released in liquid effluents to UNRESTRICTED AREAS (see Braidwood Station ODCM Annex, Appendix F, Figure F-i) shall be limited to 10 times the concentration values in Appendix B, Table 2, Column 2 to 10 CFR 20.1001-20.2402, for radionuclides other than dissolved or entrained noble gases. For dissolved or entrained noble gases, the concentration shall be limited to 2x10-4 microCurie/mI total activity.
Applicability: At all times Action:
Applicability: At all times Action:
1t       With the concentration of radioactive material released in liquid effluents to UNRESTRICTED AREAS exceeding the above limits, immediately restore the concentration to within the above limits.
1t With the concentration of radioactive material released in liquid effluents to UNRESTRICTED AREAS exceeding the above limits, immediately restore the concentration to within the above limits.
Surveillance Requirements 12.3.1.B.1       Radioactive liquid wastes shall be sampled and analyzed according to the sampling and analysis program of Table 12.3-1.
Surveillance Requirements 12.3.1.B.1 Radioactive liquid wastes shall be sampled and analyzed according to the sampling and analysis program of Table 12.3-1.
12.3.1.B.2     The results of the radioactivity analysis shall be used in accordance with the methodology and parameters in the ODCM to assure that the concentrations at the point of release are maintained within the limits of 12.3.1.A.
12.3.1.B.2 The results of the radioactivity analysis shall be used in accordance with the methodology and parameters in the ODCM to assure that the concentrations at the point of release are maintained within the limits of 12.3.1.A.
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Page 5 of 14 Bases 12.3.1.C This section is provided to ensure that the-concentration of radioactive materials released in liquid waste effluents to UNRESTRICTED AREAS will be less than 10 times the concentration values in Appendix B, Table 2, Column 2 to 10 CFR 20.1001-20.2402. This limitation provides additional assurance that the levels of radioactive materials in bodies of water in UNRESTRICTED AREAS will result in exposures within: (1) the Section II.A design objectives of Appendix 1, 10 CFR 50, to a MEMBER OF THE PUBLIC, and (2) the limits of 10 CFR 20.1301.
Attachment 10 Page 5 of 14 Bases 12.3.1.C This section is provided to ensure that the-concentration of radioactive materials released in liquid waste effluents to UNRESTRICTED AREAS will be less than 10 times the concentration values in Appendix B, Table 2, Column 2 to 10 CFR 20.1001-20.2402. This limitation provides additional assurance that the levels of radioactive materials in bodies of water in UNRESTRICTED AREAS will result in exposures within: (1) the Section II.A design objectives of Appendix 1,10 CFR 50, to a MEMBER OF THE PUBLIC, and (2) the limits of 10 CFR 20.1301.
This section applies to the release of radioactive materials in liquid effluents from all units at the site.
This section applies to the release of radioactive materials in liquid effluents from all units at the site.
The required detection capabilities for radioactive materials in liquid waste samples are tabulated in terms of the lower limits of detection (LLDs). Detailed discussion of the LLD, and other detection limits can be found in HASL Procedures Manual, HASL-300 (revised annually), Currie, L.A., "Limits for Qualitative Detection and Quantitative Determination -
The required detection capabilities for radioactive materials in liquid waste samples are tabulated in terms of the lower limits of detection (LLDs). Detailed discussion of the LLD, and other detection limits can be found in HASL Procedures Manual, HASL-300 (revised annually), Currie, L.A., "Limits for Qualitative Detection and Quantitative Determination -
Application to Radiochemistry," Anal. Chem. 40, 586-93 (1968), and Hartwell, J.K.,
Application to Radiochemistry," Anal. Chem. 40, 586-93 (1968), and Hartwell, J.K.,
        "Detection Limits for Radioana!ytical Counting Techniques," Atlantic Richfield Hanford Company Report ARH-SA-21 5 (June 1975).
"Detection Limits for Radioana!ytical Counting Techniques," Atlantic Richfield Hanford Company Report ARH-SA-21 5 (June 1975).
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Page 6 of 14 TABLE 12.3-1 RADIOACTIVE LIQUID WASTE SAMPLING AND ANALYSIS PROGRAM LIQUID RELEASE SAMPLING MINIMUM ANALYSIS TYPE OF ACTIVITY LOWER, LIMIT OF TYPE FREQUENCY FREQUENCY ANALYSIS DETECTION (LLD)(')
Attachment 10 Page 6 of 14 TABLE 12.3-1 RADIOACTIVE LIQUID WASTE SAMPLING AND ANALYSIS PROGRAM LIQUID RELEASE         SAMPLING     MINIMUM ANALYSIS           TYPE OF ACTIVITY         LOWER, LIMIT OF TYPE           FREQUENCY         FREQUENCY                     ANALYSIS           DETECTION (LLD)(')
(PiCVmI)
(PiCVmI)
I. Batch Release             P                 P             Principal Gamma Emitters(7)       5x10-7 Tanks(2)             Each Batch         Each Batch 1-131                             1xi 0. 6 P                 M             Dissolved and Entrained           1x10"5 One Batch/M                           Gases (Gamma Emitters)
I.
P                 M             H-3                               1xi 0 5 Each Batch       Composite   (3) 7 Gross Alpha                       1x1 0-P                 Q             Sr-89, Sr-90                     5x1 0-8 Each Batch       Composite (3)
Batch Release P
Fe-55                             lxi 06 7
P Principal Gamma Emitters(7) 5x10-7 Tanks(2)
: 2. Continuous                                 W             Principal Gamma Emitters(7)       5x1 0 Releases (4)       Continuous(s)     Composite(5) 1-131                             1x10s6
Each Batch Each Batch 1-131 1 xi 0.6 P
: a. Circulating Water         M                 M             Dissolved and Entrained           lx10 5 Blowdown           Grab Sample                           Gases (Gamma Emitters) 5
M Dissolved and Entrained 1x10"5 One Batch/M Gases (Gamma Emitters)
: b. Waste Water                               M                           H-3                 1x10*
P M
Treatment         Continuous(5)     Coin posite(5 )
H-3 1 xi 05 Each Batch Composite (3)
Discharge to Circulating Water Discharge 7
Gross Alpha 1 x1 0-7 P
Gross Alpha               1x1 0
Q Sr-89, Sr-90 5x1 0-8 Each Batch Composite (3)
: c. Condensate         Continuous(5 )         Q     5        Sr-89, Sr-90                     5x1 0.8 Polisher Sump                         Composite( )
Fe-55 lxi 06
Discharge 6
: 2.
Fe-55                           1x10 87
Continuous W
 
Principal Gamma Emitters(7) 5x1 0 7 Releases (4)
Attachment 10 Page 7 of 14 TABLE 12.3-1 (Continued)
Continuous(s)
RADIOACTIVE LIQUID WASTE SAMPLING AND ANALYSIS PROGRAM LIQUID RELEASE     SAMPLING   MINIMUM ANALYSIS       TYPE OF ACTIVITY LOWER LIMIT OF TYPE       FREQUENCY     FREQUENCY               ANALYSIS       DETECTION (LLD)(1)(PCi/mI)
Composite(5) 1-131 1x10s6
: 3. Continuous             W(6)         W(6)         Principal Gamma         5x10-7 Release(4)         Grab                         Emitters(7)
: a.
Essential         Sample Service Water Reactor Containment Fan Cooler (RCFC) Outlet Line 1-131                     x10"6 H-3                     lx10-5 M (6)         Dissolved and           1x10.5 Entrained Gases (Gamma Emitters)
Circulating Water M
: 4. Continuous           None           None         Principal Gamma         5x10-7 Surge Tank                                           Emitters(7)
M Dissolved and Entrained lx105 Blowdown Grab Sample Gases (Gamma Emitters)
: b.
Waste Water M
H-3 1x10*5 Treatment Continuous(5)
Coin posite(5 )
Discharge to Circulating Water Discharge Gross Alpha 1 x1 07
: c.
Condensate Continuous(5 )
Q Sr-89, Sr-90 5x1 0.8 Polisher Sump Composite(5 )
Discharge Fe-55 1x10 6 87 0
Page 7 of 14 TABLE 12.3-1 (Continued)
RADIOACTIVE LIQUID WASTE SAMPLING AND ANALYSIS PROGRAM LIQUID RELEASE SAMPLING MINIMUM ANALYSIS TYPE OF ACTIVITY LOWER LIMIT OF TYPE FREQUENCY FREQUENCY ANALYSIS DETECTION (LLD)(1)(PCi/mI)
: 3. Continuous W(6)
W(6)
Principal Gamma 5x10-7 Release(4)
Grab Emitters(7)
Essential Sample Service Water Reactor Containment Fan Cooler (RCFC) Outlet Line 1-131 x10"6 H-3 lx10-5 M (6)
Dissolved and 1x10.5 Entrained Gases (Gamma Emitters)
: 4. Continuous None None Principal Gamma 5x10-7 Surge Tank Emitters(7)
Vent-Component Cooling Water Line (8)
Vent-Component Cooling Water Line (8)
Dissolved and           I xl0 5 Entrained Gases (Gamma Emitters) 1-131                   1xl 0-6 88
Dissolved and I xl0 5 Entrained Gases (Gamma Emitters) 1-131 1xl 0-6 88 0
 
Page 8 of 14 TABLE 12.3-1 (Continued)
Attachment 10 Page 8 of 14 TABLE 12.3-1 (Continued)
RADIOACTIVE LIQUID WASTE SAMPLING AND ANALYSIS PROGRAM TABLE NOTATIONS (1)
RADIOACTIVE LIQUID WASTE SAMPLING AND ANALYSIS PROGRAM TABLE NOTATIONS (1) The LLD is defined, for purposes of these sections, as the smallest concentration of radioactive material in a sample that will yield a net count, above system background, that will be detected with 95% probability with only 5% probability of falsely concluding that a blank observation represents a "real" signal.
The LLD is defined, for purposes of these sections, as the smallest concentration of radioactive material in a sample that will yield a net count, above system background, that will be detected with 95% probability with only 5% probability of falsely concluding that a blank observation represents a "real" signal.
For a particular measurement system, which may include radiochemical separations:
For a particular measurement system, which may include radiochemical separations:
LLD =             4.66sh E x V x 2.22 x10 6 x Y x exp (-XAt)
LLD =
4.66sh E x V x 2.22 x10 6 x Y x exp (-XAt)
Where:
Where:
LLD = the lower limit of detection (microCuries per unit mass or volume),
LLD = the lower limit of detection (microCuries per unit mass or volume),
Sb = the standard deviation of the background counting rate or of the counting rate of a blank sample as appropriate (counts per minute),
Sb = the standard deviation of the background counting rate or of the counting rate of a blank sample as appropriate (counts per minute),
E = the counting efficiency (counts per disintegration),
E = the counting efficiency (counts per disintegration),
V = the sample size (units of mass or volume),
V = the sample size (units of mass or volume),
2.22 X1i06 = the number of disintegrations per minute per microCurie, Y = the fractional radiochemical yield, when applicable, k = the radioactive decay constant for the particular radionuclide (sec .), and At = the elapsed time between the midpoint of sample collection and the time of counting (sec).
6 2.22 X1i0 = the number of disintegrations per minute per microCurie, Y = the fractional radiochemical yield, when applicable, k = the radioactive decay constant for the particular radionuclide (sec.), and At = the elapsed time between the midpoint of sample collection and the time of counting (sec).
Typical values of E, V, Y, and At should be used in the calculation.
Typical values of E, V, Y, and At should be used in the calculation.
Alternative LLD Methodology An alternative methodology for LLD determination follows and is similar to the above LLD             equation:
Alternative LLD Methodology An alternative methodology for LLD determination follows and is similar to the above LLD equation:
LLD = (2.71 + 4.654/B) x Decay E x q x b x Y x t (2.22 X10 6 )
LLD = (2.71 + 4.654/B) x Decay E x q x b x Y x t (2.22 X10 6) 89 0
89
Page 9 of 14 TABLE 12.3-1 (Continued)
 
Attachment 10 Page 9 of 14 TABLE 12.3-1 (Continued)
RADIOACTIVE LIQUID WASTE SAMPLING AND ANALYSIS PROGRAM TABLE NOTATIONS Where:
RADIOACTIVE LIQUID WASTE SAMPLING AND ANALYSIS PROGRAM TABLE NOTATIONS Where:
B = background sum (counts)
B = background sum (counts)
Line 897: Line 1,234:
(k=value of the t statistic from the single-tailed t distribution at a significance level of 0.95 and infinite degrees of freedom. This means that the LLD result represents a 95% detection probability with a 5% probability of falsely concluding that the nuclide present when it is not or that the nuclide is not present when it is.)
(k=value of the t statistic from the single-tailed t distribution at a significance level of 0.95 and infinite degrees of freedom. This means that the LLD result represents a 95% detection probability with a 5% probability of falsely concluding that the nuclide present when it is not or that the nuclide is not present when it is.)
Decay = e&#xfd;t [XRT/(1 -eXRm)] [XT,(1 -e'Td)], (if applicable)
Decay = e&#xfd;t [XRT/(1 -eXRm)] [XT,(1 -e'Td)], (if applicable)
X = radioactive decay constant, (units consistent with At, RT and         Td)
X = radioactive decay constant, (units consistent with At, RT and Td)
At = "delta t', or the elapsed time between sample collection or the midpoint of sample collection and the time the count is started, depending on the type of sample, (units consistent with X)
At = "delta t', or the elapsed time between sample collection or the midpoint of sample collection and the time the count is started, depending on the type of sample, (units consistent with X)
RT= elapsed real time, or the duration of the sample count, (units consistent with k)
RT= elapsed real time, or the duration of the sample count, (units consistent with k)
Td = sample deposition time, or the duration of analyte collection onto the sample                 media',
Td = sample deposition time, or the duration of analyte collection onto the sample media',
(units consistent with X)
(units consistent with X)
The LLD may be determined using installed radioanalytical software, if available. In addition to determining the correct number of channels over which to total the background sum, utilizing the software's ability to perform decay corrections (i.e. during sample collection, from sample collection to start of analysis and during counting), this alternate method will result in a more accurate determination of the LLD.
The LLD may be determined using installed radioanalytical software, if available. In addition to determining the correct number of channels over which to total the background sum, utilizing the software's ability to perform decay corrections (i.e. during sample collection, from sample collection to start of analysis and during counting), this alternate method will result in a more accurate determination of the LLD.
90
90 0
 
Page 10 of 14 It should be recognized that the LLD is defined as a before the fact limit representing the capability of a measurement system and not as an after the fact limit for a particular measurement.
Attachment 10 Page 10 of 14 It should be recognized that the LLD is defined as a before the fact limit representing the capability of a measurement system and not as an after the fact limit for a particular measurement.
TABLE 12.3-1 (Continued)
TABLE 12.3-1 (Continued)
RADIOACTIVE LIQUID WASTE SAMPLING AND ANALYSIS PROGRAM TABLE NOTATIONS (2)   A batch release is the discharge of liquid wastes of a discrete volume. Prior to sampling for analyses, each batch shall be isolated, and then thoroughly mixed to assure representative sampling.
RADIOACTIVE LIQUID WASTE SAMPLING AND ANALYSIS PROGRAM TABLE NOTATIONS (2)
(3)   A composite sample is one in which the quantity of liquid sampled is proportional to the quantity of liquid waste discharged and in which the method of sampling employed results in a specimen that is representative of the liquids released.
A batch release is the discharge of liquid wastes of a discrete volume. Prior to sampling for analyses, each batch shall be isolated, and then thoroughly mixed to assure representative sampling.
(4)   A continuous release is the discharge of liquid wastes of a nondiscrete volume, e.g., from a volume of a system that has an input flow during the continuous release.
(3)
(5)   To be representative of the quantities and concentrations of radioactive materials in liquid effluents, samples shall be collected continuously whenever the effluent stream is flowing. Prior to analyses, all samples taken for the composite shall be thoroughly mixed in order for the composite sample to be representative of the effluent release.
A composite sample is one in which the quantity of liquid sampled is proportional to the quantity of liquid waste discharged and in which the method of sampling employed results in a specimen that is representative of the liquids released.
(6)   Not required unless the Essential Service Water RCFC Outlet Radiation Monitors RE-PRO02 and RE-PRO03 indicates measured levels greater than lx1 06 gCi/ml above background at any time               during the week.
(4)
(7)   The principal gamma emitters for which the LLD specification applies include the following radionuclides:
A continuous release is the discharge of liquid wastes of a nondiscrete volume, e.g., from a volume of a system that has an input flow during the continuous release.
(5)
To be representative of the quantities and concentrations of radioactive materials in liquid effluents, samples shall be collected continuously whenever the effluent stream is flowing. Prior to analyses, all samples taken for the composite shall be thoroughly mixed in order for the composite sample to be representative of the effluent release.
(6)
Not required unless the Essential Service Water RCFC Outlet Radiation Monitors RE-PRO02 and RE-PRO03 indicates measured levels greater than lx1 06 gCi/ml above background at any time during the week.
(7)
The principal gamma emitters for which the LLD specification applies include the following radionuclides:
Mn-54, Fe-59, Co-58, Co-60, Zn-65, Mo-99, Cs-1 34, Cs-1 37, and Ce-141. Ce-144 shall also be measured, but with an LLD of 5E-06. This list does not mean that only these nuclides are to be considered.
Mn-54, Fe-59, Co-58, Co-60, Zn-65, Mo-99, Cs-1 34, Cs-1 37, and Ce-141. Ce-144 shall also be measured, but with an LLD of 5E-06. This list does not mean that only these nuclides are to be considered.
Other gamma peaks that are identifiable, together with those of the above nuclides, shall also be analyzed and reported in the Radioactive Effluent Release Report pursuant to Section 12.6.2, in the format outlined in Regulatory Guide 1.21, Appendix B, Revision 1, June 1974.
Other gamma peaks that are identifiable, together with those of the above nuclides, shall also be analyzed and reported in the Radioactive Effluent Release Report pursuant to Section 12.6.2, in the format outlined in Regulatory Guide 1.21, Appendix B, Revision 1, June 1974.
(8)   A continuous release, is the discharge of dissolved and entrained gaseous waste from a nondiscrete liquid volume.
(8)
A continuous release, is the discharge of dissolved and entrained gaseous waste from a nondiscrete liquid volume.
12.3.2 Dose Operability Requirements 12.3.2.A The dose or dose commitment to a MEMBER OF THE PUBLIC from radioactive materials in liquid effluents released, from each unit, to UNRESTRICTED AREAS (see Braidwood Station ODCM Annex, Appendix F, Figure F-i) shall be limited:
12.3.2 Dose Operability Requirements 12.3.2.A The dose or dose commitment to a MEMBER OF THE PUBLIC from radioactive materials in liquid effluents released, from each unit, to UNRESTRICTED AREAS (see Braidwood Station ODCM Annex, Appendix F, Figure F-i) shall be limited:
: 1. During any calendar quarter to less than or equal to 1.5 mrems to the whole body and to less than or equal to 5 mrems to any organ, and
: 1.
: 2. During any calendar year to less than or equal to 3 mrems to the whole body and to less than or equal to 10 mrems to any organ.
During any calendar quarter to less than or equal to 1.5 mrems to the whole body and to less than or equal to 5 mrems to any organ, and
91
: 2.
 
During any calendar year to less than or equal to 3 mrems to the whole body and to less than or equal to 10 mrems to any organ.
Attachment 10 Page 11 of 14 Applicability: At all times.
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Page 11 of 14 Applicability: At all times.
Action:
Action:
: 1. With the calculated dose from the release of radioactive materials in liquid effluents exceeding any of the above limits, prepare and submit to the Commission within 30 days, pursuant to 10 CFR 50 Appendix I, Section IV.A, a Special Report that identifies the cause(s) for exceeding the limit(s) and defines the corrective actions that have been taken to reduce the releases and the proposed corrective actions to be taken to assure that subsequent releases will be in compliance with the above limits.
: 1.
With the calculated dose from the release of radioactive materials in liquid effluents exceeding any of the above limits, prepare and submit to the Commission within 30 days, pursuant to 10 CFR 50 Appendix I, Section IV.A, a Special Report that identifies the cause(s) for exceeding the limit(s) and defines the corrective actions that have been taken to reduce the releases and the proposed corrective actions to be taken to assure that subsequent releases will be in compliance with the above limits.
Surveillance Requirements 12.3.2.B Cumulative dose contributions from liquid effluents for the current calendar quarter and the current calendar year shall be determined in accordance with the methodology and parameters in the ODOM at least once per 31 days.
Surveillance Requirements 12.3.2.B Cumulative dose contributions from liquid effluents for the current calendar quarter and the current calendar year shall be determined in accordance with the methodology and parameters in the ODOM at least once per 31 days.
Bases 12.3.2.C This section is provided to implement the requirements of Sections II.A, Ili.A and IV.A of Appendix 1,10 CFR 50. The Operability Requirements implement the guides set forth in Section II.A of Appendix I. The ACTION statements provide the required operating flexibility and at the same time implement the guides set forth in Section IV.A of Appendix I to assure that the releases of radioactive material in liquid effluents to UNRESTRICTED AREAS will be kept "as low as is reasonably achievable." The dose calculation methodology and parameters in the ODCM implement the requirements in Section Ili.A of Appendix I that conformance with the guides of Appendix I be shown by calculational procedures based on models and data, such that the actual exposure of a MEMBER OF THE PUBLIC through appropriate pathways is unlikely to be substantially underestimated.
Bases 12.3.2.C This section is provided to implement the requirements of Sections II.A, Ili.A and IV.A of Appendix 1, 10 CFR 50. The Operability Requirements implement the guides set forth in Section II.A of Appendix I. The ACTION statements provide the required operating flexibility and at the same time implement the guides set forth in Section IV.A of Appendix I to assure that the releases of radioactive material in liquid effluents to UNRESTRICTED AREAS will be kept "as low as is reasonably achievable." The dose calculation methodology and parameters in the ODCM implement the requirements in Section Ili.A of Appendix I that conformance with the guides of Appendix I be shown by calculational procedures based on models and data, such that the actual exposure of a MEMBER OF THE PUBLIC through appropriate pathways is unlikely to be substantially underestimated.
The equations specified in the ODCM for calculating the doses due to the actual release rates of radioactive materials in liquid effluents are consistent with the methodology provided in Regulatory Guide 1.109, "Calculation of Annual Doses to Man From Routine Releases of Reactor Effluents For the Purpose of Evaluating Compliance with 10 CFR 50, Appendix I" Revision 1, October 1977 and Regulatory Guide 1.113, "Estimating Aquatic Dispersion of Effluents from Accidental and Routine Reactor Releases for the Purpose of Implementing Appendix I," April 1977.
The equations specified in the ODCM for calculating the doses due to the actual release rates of radioactive materials in liquid effluents are consistent with the methodology provided in Regulatory Guide 1.109, "Calculation of Annual Doses to Man From Routine Releases of Reactor Effluents For the Purpose of Evaluating Compliance with 10 CFR 50, Appendix I" Revision 1, October 1977 and Regulatory Guide 1.113, "Estimating Aquatic Dispersion of Effluents from Accidental and Routine Reactor Releases for the Purpose of Implementing Appendix I," April 1977.
This section applies to the release of radioactive materials in liquid effluents from each reactor at the site. When shared Radwaste Treatment Systems are used by more than one unit on a site, the wastes from all units are mixed for shared treatment; by such mixing, the effluent releases cannot accurately be ascribed to a specific unit. An estimate should be made of the contributions from each unit based on input conditions, e.g., flow rates and radioactivity concentrations, or, if not practicable, the treated effluent releases may be allocated equally to each of the radioactive waste producing units sharing the Radwaste Treatment System. For determining conformance to Operability Requirements, these allocations from shared Radwaste Treatment Systems 92
This section applies to the release of radioactive materials in liquid effluents from each reactor at the site. When shared Radwaste Treatment Systems are used by more than one unit on a site, the wastes from all units are mixed for shared treatment; by such mixing, the effluent releases cannot accurately be ascribed to a specific unit. An estimate should be made of the contributions from each unit based on input conditions, e.g., flow rates and radioactivity concentrations, or, if not practicable, the treated effluent releases may be allocated equally to each of the radioactive waste producing units sharing the Radwaste Treatment System. For determining conformance to Operability Requirements, these allocations from shared Radwaste Treatment Systems 92 0
 
Page 12 of 14 are to be added to the releases specifically attributed to each unit to obtain the total releases per unit.
Attachment 10 Page 12 of 14 are to be added to the releases specifically attributed to each unit to obtain the total releases per unit.
12.3.3 Liquid Radwaste Treatment System Operability Requirements 12.3.3.A The Liquid Radwaste Treatment System shall be OPERABLE and appropriate portions of the system shall be used to reduce releases of radioactivity when the projected doses due to the liquid effluent, from each unit, to UNRESTRICTED AREAS (see Braidwood Station ODCM Annex, Appendix F, Figure F-i) would exceed 0.06 mrem to the whole body or 0.2 mrem to any organ in a 31-day period.
12.3.3 Liquid Radwaste Treatment System Operability Requirements 12.3.3.A The Liquid Radwaste Treatment System shall be OPERABLE and appropriate portions of the system shall be used to reduce releases of radioactivity when the projected doses due to the liquid effluent, from each unit, to UNRESTRICTED AREAS (see Braidwood Station ODCM Annex, Appendix F, Figure F-i) would exceed 0.06 mrem to the whole body or 0.2 mrem to any organ in a 31-day period.
Applicability: At all times.
Applicability: At all times.
Action:
Action:
: 1. With radioactive liquid waste being discharged without treatment and in excess of the above limits and any portion of the Liquid Radwaste Treatment System not in operation, prepare and submit to the Commission within 30 days, pursuant to 10 CFR 50 Appendix I, Section IV.A, a Special Report that includes the following information:
: 1.
: a.       Explanation of why liquid radwaste was being discharged without treatment, identification of any inoperable equipment or subsystems, and the reason for the inoperability,
With radioactive liquid waste being discharged without treatment and in excess of the above limits and any portion of the Liquid Radwaste Treatment System not in operation, prepare and submit to the Commission within 30 days, pursuant to 10 CFR 50 Appendix I, Section IV.A, a Special Report that includes the following information:
: b.       Action(s) taken to restore the inoperable equipment to OPERABLE status, and
: a.
: c.       Summary description of action(s) taken to prevent a recurrence.
Explanation of why liquid radwaste was being discharged without treatment, identification of any inoperable equipment or subsystems, and the reason for the inoperability,
Surveillance Requirements 12.3.3.B.1       Doses due to liquid releases from each unit to UNRESTRICTED AREAS shall be projected at least once per 31 days in accordance With the methodology and parameters in the ODCM when the Liquid Radwaste Treatment System is not being fully utilized.
: b.
12.3.3.B.2       The installed Liquid Radwaste Treatment System shall be considered OPERABLE by meeting Sections 12.3.1.A and 12.3.2.A.
Action(s) taken to restore the inoperable equipment to OPERABLE status, and
Bases 12.3.3.C         The OPERABILITY of the Liquid Radwaste Treatment System ensures that this system will be available for use whenever liquid effluents require treatment prior to release to the environment. The requirement that the appropriate portions of this system be used when specified provides assurance that the releases of radioactive materials in liquid effluents will be kept "as low as is reasonably achievable". This section implements the requirements of 10 CFR 50.36a, General Design Criterion 60 of Appendix A to 10 CFR 50 and the design objective given in Section 11.D of Appendix I-to 10 CFR 50.
: c.
93
Summary description of action(s) taken to prevent a recurrence.
 
Surveillance Requirements 12.3.3.B.1 Doses due to liquid releases from each unit to UNRESTRICTED AREAS shall be projected at least once per 31 days in accordance With the methodology and parameters in the ODCM when the Liquid Radwaste Treatment System is not being fully utilized.
Attachment 10 Page 13 of 14 The specified limits governing the use of appropriate portions of the Liquid Radwaste Treatment System were specified as a suitable fraction of the dose design objectives set forth in Section II.A of Appendix 1, 10 CFR 50, for liquid effluents.
12.3.3.B.2 The installed Liquid Radwaste Treatment System shall be considered OPERABLE by meeting Sections 12.3.1.A and 12.3.2.A.
Bases 12.3.3.C The OPERABILITY of the Liquid Radwaste Treatment System ensures that this system will be available for use whenever liquid effluents require treatment prior to release to the environment. The requirement that the appropriate portions of this system be used when specified provides assurance that the releases of radioactive materials in liquid effluents will be kept "as low as is reasonably achievable". This section implements the requirements of 10 CFR 50.36a, General Design Criterion 60 of Appendix A to 10 CFR 50 and the design objective given in Section 11.D of Appendix I-to 10 CFR 50.
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Page 13 of 14 The specified limits governing the use of appropriate portions of the Liquid Radwaste Treatment System were specified as a suitable fraction of the dose design objectives set forth in Section II.A of Appendix 1, 10 CFR 50, for liquid effluents.
This section applies to the release of radioactive materials in liquid effluents from each unit at the site. When shared Radwaste Treatment Systems are used by more than one unit on a site, the wastes from all units are mixed for shared treatment; by such mixing, the effluent releases cannot accurately be ascribed to a specific unit. An estimate should be made of the contributions from each unit based on input conditions, e.g., flow rates and radioactivity concentrations, or, if not practicable, the treated effluent releases may be allocated equally to each of the radioactive waste producing units sharing the Radwaste Treatment System.
This section applies to the release of radioactive materials in liquid effluents from each unit at the site. When shared Radwaste Treatment Systems are used by more than one unit on a site, the wastes from all units are mixed for shared treatment; by such mixing, the effluent releases cannot accurately be ascribed to a specific unit. An estimate should be made of the contributions from each unit based on input conditions, e.g., flow rates and radioactivity concentrations, or, if not practicable, the treated effluent releases may be allocated equally to each of the radioactive waste producing units sharing the Radwaste Treatment System.
For determining conformance to Operability Requirements, these allocations from shared Radwaste Treatment Systems are to be added to the releases specifically attributed to each unit to obtain the total releases per unit.
For determining conformance to Operability Requirements, these allocations from shared Radwaste Treatment Systems are to be added to the releases specifically attributed to each unit to obtain the total releases per unit.
Line 949: Line 1,296:
Review of Braidwood ODCM Table 11-1 section 3.a, Ground / well water indicates that there are (5) drinking water wells currently being monitored.
Review of Braidwood ODCM Table 11-1 section 3.a, Ground / well water indicates that there are (5) drinking water wells currently being monitored.
Braidwood ODCM Table 12.5-1 Section 3.a and note (6) to the table discusses the need for groundwater monitoring when the irrigation pathway is a credible pathway. The hydraulic gradient at Braidwood indicates that shallow wells could become contaminated. ODCM Section 4.3 states that the only liquid pathways used are the potable water and fish ingestion pathways. The irrigation to food crop pathway associated with the groundwater contamination should be evaluated. (CAll)
Braidwood ODCM Table 12.5-1 Section 3.a and note (6) to the table discusses the need for groundwater monitoring when the irrigation pathway is a credible pathway. The hydraulic gradient at Braidwood indicates that shallow wells could become contaminated. ODCM Section 4.3 states that the only liquid pathways used are the potable water and fish ingestion pathways. The irrigation to food crop pathway associated with the groundwater contamination should be evaluated. (CAll)
Monitoring for other nuclides 40 CFR 141 and 35 IAC 620 specify limits on radionuclides other than tritium. As part of Braidwood's recovery plan, gamma-emitting fission and activation products as well as other beta-emitting nuclides (Strontium-89, and Strontium-90) are being analyzed. The gamma-emitting nuclide analytical results indicate normal background levels. Strontium-89 and Strontium-90 results indicate normal background levels.
Monitoring for other nuclides 40 CFR 141 and 35 IAC 620 specify limits on radionuclides other than tritium. As part of Braidwood's recovery plan, gamma-emitting fission and activation products as well as other beta-emitting nuclides (Strontium-89, and Strontium-90) are being analyzed.
94
The gamma-emitting nuclide analytical results indicate normal background levels. Strontium-89 and Strontium-90 results indicate normal background levels.
 
94 0
Attachment 10 Page 14 of 14 Generic Chapters Revision 3 January, 2002 Table 2-1 Regulatory Dose Limit Matrix REGULATION                             DOSE TYPE                       DOSE LIMIT(s) 3               ODCM EQUATION Liquid Releases:                                                           (quarterly)     (annual) 10 CFR 50 App. V3         Whole (Total) Body Dose                         1.5 mrem       3 mrem           A-17 (per reactor unit)
Page 14 of 14 Generic Chapters Revision 3 January, 2002 Table 2-1 Regulatory Dose Limit Matrix REGULATION DOSE TYPE DOSE LIMIT(s)3 ODCM EQUATION Liquid Releases:
Organ Dose (per reactor unit)                     5 mrem         10 mrem         A-17 Technical Specifications   The concentration of radioactivity in liquid   Ten (10) times the effluents released to unrestricted areas       concentration values listed       A-21 in 10 CFR 20 Appendix B; Table 2, Column 2, Table C-6 of ODCM Appendix C for Noble Gases Total Doses 1:
(quarterly)
10 CFR 20.1301 (a)(1)     Total Effective Dose Equivalent 4                       100 mrem/yr               A-25 10 CFR 20.1301 (d)         Total Body Dose                                         25 mrem/_yr               A-25 and 40 CFR 190             Thyroid Dose                                           75 mrem/yr               A-25 Other Organ Dose                                       25 mrem__/yr             A-25 Other Limits       2:
(annual) 10 CFR 50 App. V3 Whole (Total) Body Dose 1.5 mrem 3 mrem A-17 (per reactor unit)
40 CFR 141                 Total Body Dose Due to Drinking Water From               4 mrem/yr               A-17 Public Water Systems Organ Dose Due to Drinking Water From                   4 mrem/yr               A- 17 Public Water Systems 1 These doses are calculated considering all sources of radiation and               radioactivity in effluents.
Organ Dose (per reactor unit) 5 mrem 10 mrem A-17 Technical Specifications The concentration of radioactivity in liquid Ten (10) times the effluents released to unrestricted areas concentration values listed A-21 in 10 CFR 20 Appendix B; Table 2, Column 2, Table C-6 of ODCM Appendix C for Noble Gases Total Doses 1:
2 These limits are not directly applicable to nuclear power stations.               They are applicable to the owners or operators of public water systems. However, the RETS of some of the Exelon Nuclear power stations require assessment of compliance with these limits. For additional information, see Section A.6 of Appendix A.
10 CFR 20.1301 (a)(1)
3   Note that 10 CFR 50 provides design objectives not limits.
Total Effective Dose Equivalent 4 100 mrem/yr A-25 10 CFR 20.1301 (d)
4   Compliance with 10 CFR 20.1301(a)(1) is demonstrated by compliance with 40 CFR 190. Note that it may be necessary to address dose from onsite activity by members of the public as well.
Total Body Dose 25 mrem/_yr A-25 and 40 CFR 190 Thyroid Dose 75 mrem/yr A-25 Other Organ Dose 25 mrem__/yr A-25 Other Limits 2:
95
40 CFR 141 Total Body Dose Due to Drinking Water From 4 mrem/yr A-17 Public Water Systems Organ Dose Due to Drinking Water From 4 mrem/yr A-17 Public Water Systems 1 These doses are calculated considering all sources of radiation and radioactivity in effluents.
 
2 These limits are not directly applicable to nuclear power stations. They are applicable to the owners or operators of public water systems. However, the RETS of some of the Exelon Nuclear power stations require assessment of compliance with these limits. For additional information, see Section A.6 of Appendix A.
Attachment 11 Root Cause Report Quality Checklist
3 Note that 10 CFR 50 provides design objectives not limits.
                                                        .Page 1 of 2.
4 Compliance with 10 CFR 20.1301(a)(1) is demonstrated by compliance with 40 CFR 190. Note that it may be necessary to address dose from onsite activity by members of the public as well.
A. Critical Content Attributes                                         YES NO
95 1
: 1. Is the condition that requires resolution adequately and accurately identified?                                             X
Root Cause Report Quality Checklist
: 2. Are inappropriate actions and equipment failures (causal factors) identified?                                               X
.Page 1 of 2.
: 3. Are the causes accurately identified, including root causes and contributing causes?                                               X
A.
: 4. Are there corrective actions to prevent recurrence identified for each root cause and do they tie DIRECTLY to the root cause?
Critical Content Attributes YES NO
AND, are there corrective actions for contributing cause and do     X they tie DIRECTLY to the contributing cause?
: 1.
: 5. Have the root cause analysis techniques been appropriately used and documented?                                               X
Is the condition that requires resolution adequately and accurately identified?
: 6. Was an Event and Causal Factors Chart properly prepared?           X
X
: 7. Does the report adequately and accurately address the extent of condition in accordance with the guidance provided in               X Attachment 3 of LS-AA-125-1003, Reference 4.3?
: 2.
: 8. Does the report adequately and accurately address plant specific risk consequences?                                         X
Are inappropriate actions and equipment failures (causal factors) identified?
: 9. Does the report adequately and accurately address programmatic and organizational issues?                             X
X
: 10. Have previoussimilar events been evaluated? Has an Operating Experience database search been performed to determine whether the problem was preventable if industry experience         X had been adequately implemented?
: 3.
96
Are the causes accurately identified, including root causes and contributing causes?
 
X
Attachment 11 Root Cause Report Quality Checklist Page 2 of 2 B. Important Content Attributes
: 4.
: 1. Are all of the important facts included in the report?             X
Are there corrective actions to prevent recurrence identified for each root cause and do they tie DIRECTLY to the root cause?
: 2. Does the report explain the logic used to arrive at the           X conclusions?
AND, are there corrective actions for contributing cause and do X
: 3. If appropriate, does the report explain what root causes were     X considered, but eliminated from further consideration and the bases for their elimination from consideration?
they tie DIRECTLY to the contributing cause?
: 4. Does the report identify contributing causes, if applicable?       X
: 5.
: 5. Is it clear what conditions the corrective actions are intended to X create?
Have the root cause analysis techniques been appropriately used and documented?
: 6. Are there unnecessary corrective actions that do not address the     X root causes or contributing causes?
X
: 7. Is the timing for completion of each corrective action             X commensurate with the importance or risk associated with the issue?
: 6.
C. Miscellaneous Items
Was an Event and Causal Factors Chart properly prepared?
: 1.                 Did an individual who is qualified in Root Cause     X Analysis prepare the report?
X
: 2.                 Does the Executive Summary adequately and             X accurately describe the significance of the event, the event sequence, root causes, corrective actions, reportability, and previous events?
: 7.
: 3.                 Do the corrective actions include an effectiveness   X review for corrective actions to prevent recurrence?
Does the report adequately and accurately address the extent of condition in accordance with the guidance provided in X of LS-AA-125-1003, Reference 4.3?
: 4.                 Were ALL corrective actions entered and verified to   X be in Action Tracking?             "
: 8.
: 5.                 Are the format, composition, and rhetoric acceptable X (grammar, typographical errors, spelling, acronyms, etc.)?
Does the report adequately and accurately address plant specific risk consequences?
97
X
 
: 9.
Attachment 12 Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)
Does the report adequately and accurately address programmatic and organizational issues?
X
: 10.
Have previoussimilar events been evaluated? Has an Operating Experience database search been performed to determine whether the problem was preventable if industry experience X
had been adequately implemented?
96 1
Root Cause Report Quality Checklist Page 2 of 2 B.
Important Content Attributes
: 1.
Are all of the important facts included in the report?
X
: 2.
Does the report explain the logic used to arrive at the X
conclusions?
: 3.
If appropriate, does the report explain what root causes were X
considered, but eliminated from further consideration and the bases for their elimination from consideration?
: 4.
Does the report identify contributing causes, if applicable?
X
: 5.
Is it clear what conditions the corrective actions are intended to X
create?
: 6.
Are there unnecessary corrective actions that do not address the X
root causes or contributing causes?
: 7.
Is the timing for completion of each corrective action X
commensurate with the importance or risk associated with the issue?
C.
Miscellaneous Items
: 1.
Did an individual who is qualified in Root Cause X
Analysis prepare the report?
: 2.
Does the Executive Summary adequately and X
accurately describe the significance of the event, the event sequence, root causes, corrective actions, reportability, and previous events?
: 3.
Do the corrective actions include an effectiveness X
review for corrective actions to prevent recurrence?
: 4.
Were ALL corrective actions entered and verified to X
be in Action Tracking?
: 5.
Are the format, composition, and rhetoric acceptable X
(grammar, typographical errors, spelling, acronyms, etc.)?
97 2
Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)
Event Timeline Page l of 13 Vacuum Breaker #3 (VB-3)
Event Timeline Page l of 13 Vacuum Breaker #3 (VB-3)
December 1997
December 1997 VB-3 was inspected (PM 00079293) with no water leakage noted.
* VB-3 was inspected (PM 00079293) with no water leakage noted.
December, 3 to 4, 1998 VB-3 was discovered leaking, due to water hammer failure of the air vent valve line (RC 38237-02).
December, 3 to 4, 1998 VB-3 was discovered leaking, due to water hammer failure of the air vent valve line (RC 38237-02). The Problem Identification Form (PIF) for this event (A1998-04324) was closed to no concern, based on the water being contained onsite and apparently personnel not aware of a tritium concern (Root Cause 4). The PIF stated that the water was in the ditch, which Exelon owns. PIF A1998-04324 stated the repair (temporary) to stop the leak was completed within 24 hours (12/05/1998) under WO 98127749. This section of ditch is blocked at both ends. The size/amount of leakage was not recorded due to a lack of monitoring instrumentation (Other Issue "a"), but was estimated in 2000 to be similar to the 2000 VB-2 leakage at approximately 3 million gallons over a 30-day period. No integrated spill response procedure was in place to guide adequate station response. ( Root Cause 3)
The Problem Identification Form (PIF) for this event (A1998-04324) was closed to no concern, based on the water being contained onsite and apparently personnel not aware of a tritium concern (Root Cause 4). The PIF stated that the water was in the ditch, which Exelon owns. PIF A1998-04324 stated the repair (temporary) to stop the leak was completed within 24 hours (12/05/1998) under WO 98127749. This section of ditch is blocked at both ends. The size/amount of leakage was not recorded due to a lack of monitoring instrumentation (Other Issue "a"), but was estimated in 2000 to be similar to the 2000 VB-2 leakage at approximately 3 million gallons over a 30-day period.
December 1998 Spill Conclusion In 1998, VB-3 failed and released approximately three million gallons producing standing surface water on Braidwood property.         Problem Identification Form (PIF) A1998-04324
No integrated spill response procedure was in place to guide adequate station response. ( Root Cause 3)
December 1998 Spill Conclusion In 1998, VB-3 failed and released approximately three million gallons producing standing surface water on Braidwood property.
Problem Identification Form (PIF) A1998-04324
[equivalent to today's Issue Report (IR)] was created to document and address this spill. The response to this event was to isolate the valve and repair the valve as soon as possible. The Braidwood NPDES Coordinator was notified and determined that there were no environmental concerns because the water had not reached a waterway. The environmental procedures concentrate on NPDES compliance associated with oil or hazardous materials and by design, provide no guidance on radiological spills (Failed Barriers 1 & 2).
[equivalent to today's Issue Report (IR)] was created to document and address this spill. The response to this event was to isolate the valve and repair the valve as soon as possible. The Braidwood NPDES Coordinator was notified and determined that there were no environmental concerns because the water had not reached a waterway. The environmental procedures concentrate on NPDES compliance associated with oil or hazardous materials and by design, provide no guidance on radiological spills (Failed Barriers 1 & 2).
The Reportability Manual (LS-AA-1 020 & 1110) does not reflect ODCM REMP/RETS reporting requirements for unplanned release paths (Faile.d Barriers 7-11). Also, these procedures do not reflect 35 IAC 620 groundwater tritium requirements (Failed Barriers 7-11). At the time, Operations personnel believed (through interviews) that the water leaking from the CW B/D VB was procedurally treated and approved for radiological release to the environment (Kankakee River) and they assumed it to be radiologically acceptable if it leaked to the ground.
The Reportability Manual (LS-AA-1 020 & 1110) does not reflect ODCM REMP/RETS reporting requirements for unplanned release paths (Faile.d Barriers 7-11). Also, these procedures do not reflect 35 IAC 620 groundwater tritium requirements (Failed Barriers 7-11). At the time, Operations personnel believed (through interviews) that the water leaking from the CW B/D VB was procedurally treated and approved for radiological release to the environment (Kankakee River) and they assumed it to be radiologically acceptable if it leaked to the ground.
Engineering interviews indicated that they were aware of diluted radioactive waste effluent in the CW B/D line, but since there had been no training for the requirements or the implications of a CW B/D water spill, the creation of a work request and issue report would be an adequate response to correct the leak during the next scheduled work week.
Engineering interviews indicated that they were aware of diluted radioactive waste effluent in the CW B/D line, but since there had been no training for the requirements or the implications of a CW B/D water spill, the creation of a work request and issue report would be an adequate response to correct the leak during the next scheduled work week.
98
98 2
 
Vacuum Breaker,#3 (VB-3) and Vacuum Breaker 2 (VB-2)
Attachment 12 Vacuum Breaker,#3 (VB-3) and Vacuum Breaker 2 (VB-2)
Event Timeline Page 2 of 13 The Event Screening Committee (the equivalent of today's Braidwood Senior Management Review Committee) reviewed PIF A1998-04324 and assigned no actions to inquire into or address radiological concerns. As a consequence, no action items were created to track the characterization, remediation and documentation of this spill. Radiological concerns were not recognized. There was no documentation that any spill remediation was performed. A root cause for the ineffective response was weak management review and oversight of spill response activities (Root Cause 4).
Event Timeline Page 2 of 13 The Event Screening Committee (the equivalent of today's Braidwood Senior Management Review Committee) reviewed PIF A1998-04324 and assigned no actions to inquire into or address radiological concerns. As a consequence, no action items were created to track the characterization, remediation and documentation of this spill. Radiological concerns were not recognized. There was no documentation that any spill remediation was performed. A root cause for the ineffective response was weak management review and oversight of spill response activities (Root Cause 4). In this event , the knowledgeable personnel with the radiological expertise were not brought to bear. The root cause was determined to be a lack of integrated procedural guidance to ensure proper recognition, evaluation, and timely mitigation of the spill events (Root Cause 3) to ensure proper identification, timely mitigation and evaluation of the spill events, including knowledge of local hydrology, the impact of low-level tritium leaks, and groundwater regulations.
In this event, the knowledgeable personnel with the radiological expertise were not brought to bear. The root cause was determined to be a lack of integrated procedural guidance to ensure proper recognition, evaluation, and timely mitigation of the spill events (Root Cause 3) to ensure proper identification, timely mitigation and evaluation of the spill events, including knowledge of local hydrology, the impact of low-level tritium leaks, and groundwater regulations.
Documentation associated with the response does not indicate recognition that a potential radioactive spill had occurred. Had it been recognized that the 1998 release of tritium to an unplanned location (the field in the vicinity of VB-3) was a radiological release, a more rigorous characterization and remediation response may have been initiated. A lack of recognition by the Operations Department personnel (who initiate and secure the release of processed radioactive waste into the CW B/D System) and/or the Radiological Protection personnel (who sample and analyze the release tanks prior to concurring with the release), would be a missed opportunity.
Documentation associated with the response does not indicate recognition that a potential radioactive spill had occurred. Had it been recognized that the 1998 release of tritium to an unplanned location (the field in the vicinity of VB-3) was a radiological release, a more rigorous characterization and remediation response may have been initiated. A lack of recognition by the Operations Department personnel (who initiate and secure the release of processed radioactive waste into the CW B/D System) and/or the Radiological Protection personnel (who sample and analyze the release tanks prior to concurring with the release), would be a missed opportunity.
Additionally, the 1998 Annual Effluent Report did not contain an evaluation of the vacuum breaker radioactivity released and did not contain the associated evaluation of the dose to the public (IR 455079) & (CA-15). No documentation was located that implied a recognition of vacuum breaker leakage impact on the requirements of the ODCM, REMP, and 10CFR50.75(g).
Additionally, the 1998 Annual Effluent Report did not contain an evaluation of the vacuum breaker radioactivity released and did not contain the associated evaluation of the dose to the public (IR 455079) & (CA-15). No documentation was located that implied a recognition of vacuum breaker leakage impact on the requirements of the ODCM, REMP, and 10CFR50.75(g).
The root cause of the large volume leaks in 1998 and 2000 is documented in Root Cause Report (RCR) 38237, which determined that the Circulating Water (CW) Blowdown (B/D)
The root cause of the large volume leaks in 1998 and 2000 is documented in Root Cause Report (RCR) 38237, which determined that the Circulating Water (CW) Blowdown (B/D)
Vacuum Breaker (VB) Valves had inadequate preventative maintenance programs and inadequate design configuration (Root Cause 1).
Vacuum Breaker (VB) Valves had inadequate preventative maintenance programs and inadequate design configuration (Root Cause 1).
November 15, 2000 Condition Report (CR) A2000-04389 was written which stated that the 1998 response to PIF Al 998-04324 was inadequate, as a result of Root Cause Report (RCR) 38237/CR A2000-04281. CR A2000-04389 resulted in an action to Radiation Protection to perform a radiological evaluation under 10 CFR 50.75(g). June 18, 2001 99
November 15, 2000 Condition Report (CR) A2000-04389 was written which stated that the 1998 response to PIF Al 998-04324 was inadequate, as a result of Root Cause Report (RCR) 38237/CR A2000-04281.
 
CR A2000-04389 resulted in an action to Radiation Protection to perform a radiological evaluation under 10 CFR 50.75(g). June 18, 2001 99 2
Attachment 12 Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)
Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)
Event Timeline Page 3 of 13 CR A2001-01806 reported VB-3 leaking. WC-AA-106 did not have tritium concerns integrated into the work prioritization. At this time, there was no guidance in the CW B/D procedures to secure radiological releases when known leaks were discovered. (Root Cause 3)
Event Timeline Page 3 of 13 CR A2001-01806 reported VB-3 leaking.
WC-AA-106 did not have tritium concerns integrated into the work prioritization. At this time, there was no guidance in the CW B/D procedures to secure radiological releases when known leaks were discovered. (Root Cause 3)
Note: Little to no information could be found in PIF's or WR/WO's for this event.
Note: Little to no information could be found in PIF's or WR/WO's for this event.
Therefore, little data could be retrieved by this Root Cause Investigation Team (IR 428868) other than from personnel interviews.
Therefore, little data could be retrieved by this Root Cause Investigation Team (IR 428868) other than from personnel interviews.
July 21, 2001
July 21, 2001 CR A2000-04389's 10 CFR 50.75(g) Radiological Assessment Report was completed based on samples obtained in April 2001.
* CR A2000-04389's 10 CFR         50.75(g) Radiological Assessment Report was completed based on samples obtained     in April 2001. In retrospect, the 1998 VB-3 spill site was inadequately characterized,     due to the lack of groundwater assessment for tritium concentrations. Therefore,     the evaluation erroneously concluded that there was no further action required.
In retrospect, the 1998 VB-3 spill site was inadequately characterized, due to the lack of groundwater assessment for tritium concentrations.
July 23, 2001
Therefore, the evaluation erroneously concluded that there was no further action required.
* Revision 2 of WO 98127749 to repair VB-3 is authorized for work by Operations. The WO comments stated that leaking water prevented work completion. The WO did not contain precautions regarding tritium leakage, due to ATI 106767-04 (May 2002) comments not being incorporated into the WO. (OtherIssue "b")
July 23, 2001 Revision 2 of WO 98127749 to repair VB-3 is authorized for work by Operations. The WO comments stated that leaking water prevented work completion. The WO did not contain precautions regarding tritium leakage, due to ATI 106767-04 (May 2002) comments not being incorporated into the WO. (Other Issue "b")
December 2001
December 2001 VB-3 was inspected (WO 99284438) with no water leakage noted.
* VB-3 was inspected (WO 99284438) with no water leakage noted.
May 4, 2002 VB-3 pilot (air release) valve seat was discovered leaking water. WO 004402131 and IR 106767 were written.
May 4, 2002
100 2
* VB-3 pilot (air release) valve seat was discovered leaking water. WO 004402131 and IR 106767 were written.
Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)
100
Event Timeline Page 4 of 13 May 20, 2002 Revision 2 of WO 98127749 to repair the isolation valve for VB-3 was completed, with no mention of radiological controls for the water discovered in the vacuum breaker pit. (Root Cause 3)
 
Attachment 12 Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)
Event Timeline Page 4 of 13 May 20, 2002
* Revision 2 of WO 98127749 to repair the isolation valve for VB-3 was completed, with no mention of radiological controls for the water discovered in the vacuum breaker pit. (Root Cause 3)
August 29, 2003 Water was found in the VB-3 valve pit during walkdown surveillance. WR 00110407 and IR 173688 were written. The IR indicates water is most likely groundwater intrusion into the pit. There was no observed leakage from VB-3.
August 29, 2003 Water was found in the VB-3 valve pit during walkdown surveillance. WR 00110407 and IR 173688 were written. The IR indicates water is most likely groundwater intrusion into the pit. There was no observed leakage from VB-3.
March 17, 2005 The Illinois Environmental Protection Agency (IEPA) contacted Exelon concerning an investigation of tritium concentrations in wells near Braidwood Station in preparation for the Godley public hearing. Sampling to investigate this report was commenced. (IR 328451)
March 17, 2005 The Illinois Environmental Protection Agency (IEPA) contacted Exelon concerning an investigation of tritium concentrations in wells near Braidwood Station in preparation for the Godley public hearing. Sampling to investigate this report was commenced.
(IR 328451)
November 30, 2005
November 30, 2005
* Issue Report (IR) 428868 reports tritium concentrations from what appears to be the area of the 1998 spill, have migrated offsite with a potential to affect the public via tritiated groundwater. (EVENT)
* Issue Report (IR) 428868 reports tritium concentrations from what appears to be the area of the 1998 spill, have migrated offsite with a potential to affect the public via tritiated groundwater. (EVENT)
Vacuum Breaker 2 (VB-2)
Vacuum Breaker 2 (VB-2)
December 1996
December 1996 VB-2 was inspected (PM 00079293) with no water leakage noted.
* VB-2 was inspected (PM 00079293) with no water leakage noted.
January 5, 1998 Water leak discovered on the VB-2 pilot (air release) valve seat. WR 9800691 was written.
January 5, 1998
101 2
* Water leak discovered on the VB-2 pilot (air release) valve seat.     WR 9800691 was written.
Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)
101
Event Timeline Page 5 of 13 May 24, 2000 VB-2-found leaking. Issue tracked via WR 9800691.
 
Attachment 12 Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)
Event Timeline Page 5 of 13 May 24, 2000
* VB-2-found leaking. Issue tracked via WR 9800691.
November 6, 2000 14:30 The Braidwood National Pollutant Discharge Elimination System (NPDES) Coordinator received a call from the Illinois Environmental Protection Agency (IEPA) regarding standing water in a ditch immediately adjacent to private property along the south side of Smiley Road. An area resident had reported the water and noted that the water had been present in the ditch for approximately 7-10 days prior to IEPA notification.
November 6, 2000 14:30 The Braidwood National Pollutant Discharge Elimination System (NPDES) Coordinator received a call from the Illinois Environmental Protection Agency (IEPA) regarding standing water in a ditch immediately adjacent to private property along the south side of Smiley Road. An area resident had reported the water and noted that the water had been present in the ditch for approximately 7-10 days prior to IEPA notification.
Suspecting a faulty vacuum breaker, the NPDES Coordinator notified the Shift Manager and Outage Control Center (OCC) Director of the IEPA notification.
Suspecting a faulty vacuum breaker, the NPDES Coordinator notified the Shift Manager and Outage Control Center (OCC) Director of the IEPA notification.
Line 1,049: Line 1,439:
The NPDES Coordinator assessed the site and concluded that the water was confined to site property which included the ditch along the south side of Smiley Road.
The NPDES Coordinator assessed the site and concluded that the water was confined to site property which included the ditch along the south side of Smiley Road.
* The Braidwood NPDES Coordinator notified the IEPA of his findings regarding the water source and the boundaries of the discharge. Station NPDES monitoring requirements were discussed and the IEPA requested no additional sampling. The Braidwood NPDES Coordinator determined that there were no NPDES concerns since the water was contained and not discharging to "Waters of the State".
* The Braidwood NPDES Coordinator notified the IEPA of his findings regarding the water source and the boundaries of the discharge. Station NPDES monitoring requirements were discussed and the IEPA requested no additional sampling. The Braidwood NPDES Coordinator determined that there were no NPDES concerns since the water was contained and not discharging to "Waters of the State".
* The VB-2 leakage was estimated to be a maximum of 3 million gallons. This leakage was the result of corrosion of the vacuum breaker assembly and water hammer, which broke the float in VB-2, exposing an 8" opening.
The VB-2 leakage was estimated to be a maximum of 3 million gallons. This leakage was the result of corrosion of the vacuum breaker assembly and water hammer, which broke the float in VB-2, exposing an 8" opening.
102
102 2
 
Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)
Attachment 12 Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)
Event Timeline Page 6 of 13 November 6, 2000 16:00 -17:00 A meeting was held with Braidwood Senior Management, the Shift Manager and the Outage Control Center (OCC) staff. The Braidwood NPDES Coordinator briefed the attendees on the results of his field observations of the area surrounding the vacuum breaker valve.
Event Timeline Page 6 of 13 November 6, 2000 16:00 -17:00 A meeting was held with Braidwood Senior Management, the Shift Manager and the Outage Control Center (OCC) staff. The Braidwood NPDES Coordinator briefed the attendees on the results of his field observations of the area surrounding the vacuum breaker valve. Braidwood Senior Management was also briefed on the discussions between the Braidwood NPDES Coordinator and the IEPA.                 Braidwood Senior Management directed the following actions be taken:
Braidwood Senior Management was also briefed on the discussions between the Braidwood NPDES Coordinator and the IEPA.
: 1.     Operating personnel were to evaluate water inventories and to explore potential alternate release options.
Braidwood Senior Management directed the following actions be taken:
: 2.     Isolate the CW B/D system
: 1.
: 3.     Make preparations to take the CW B/D system out of service, drain the piping section and replace the failed vacuum breaker valve.
Operating personnel were to evaluate water inventories and to explore potential alternate release options.
: 2.
Isolate the CW B/D system
: 3.
Make preparations to take the CW B/D system out of service, drain the piping section and replace the failed vacuum breaker valve.
The CW B/D system was then isolated in preparation for draining and repairs. There was no discussion at this time of any need to sample for radioactivity in the water that had been discharged. The thought process was that any radioactivity in the water had been diluted per procedure and was acceptable for discharge to the environment (i.e., the Kankakee River). [This is based on Operations Department personnel interviews.]
The CW B/D system was then isolated in preparation for draining and repairs. There was no discussion at this time of any need to sample for radioactivity in the water that had been discharged. The thought process was that any radioactivity in the water had been diluted per procedure and was acceptable for discharge to the environment (i.e., the Kankakee River). [This is based on Operations Department personnel interviews.]
November 7, 2000 06:15
November 7, 2000 06:15 The Braidwood Operations Manager notified the Braidwood Radiation Protection (RP)
    , The Braidwood Operations Manager notified the Braidwood Radiation Protection (RP)
Manager that there was a blowdown line leak and that RP was to meet with the Braidwood Chemistry Manager to look at potential alternate radioactive release paths.
Manager that there was a blowdown line leak and that RP was to meet with the Braidwood Chemistry Manager to look at potential alternate radioactive release paths.
The reason for this request was that radioactive releases would not be possible via the blowdown system while blowdown was isolated for repairs to VB-2.
The reason for this request was that radioactive releases would not be possible via the blowdown system while blowdown was isolated for repairs to VB-2.
* Following this phone conversation, the Braidwood RP Manager notified the Braidwood RP Technical Superintendent regarding the need to collect samples of available water.
Following this phone conversation, the Braidwood RP Manager notified the Braidwood RP Technical Superintendent regarding the need to collect samples of available water.
103
103 2
 
Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)
Attachment 12 Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)
Event Timeline Page T7of 13 November 7, 2000 08:00 A decision to conduct confirmatory sampling of the water leaking from the manway cover of the vacuum breaker structure was made.
Event Timeline Page T7of 13 November 7, 2000 08:00 A decision to conduct confirmatory sampling of the water leaking from the manway cover of the vacuum breaker structure was made. The sample was taken at approximately 0845 and the results of the gamma isotopic analysis indicated no detectable radioactivity. Isotopic analysis indicated no detectable tritium.
The sample was taken at approximately 0845 and the results of the gamma isotopic analysis indicated no detectable radioactivity. Isotopic analysis indicated no detectable tritium.
* Braidwood chemistry manager contacts corporate environmental and asks them to report to the site to help assess the event.
Braidwood chemistry manager contacts corporate environmental and asks them to report to the site to help assess the event.
Decision is made by Braidwood Senior Management to sample both soil and water at the vacuum breaker.
Decision is made by Braidwood Senior Management to sample both soil and water at the vacuum breaker.
November 7, 2000 08:30 Mechanical Maintenance Department (MMD) personnel with assistance from System Engineering pumped out the VB-2 vault back into the B/D line and began draining the blowdown piping to facilitate work on VB-2.
November 7, 2000 08:30 Mechanical Maintenance Department (MMD) personnel with assistance from System Engineering pumped out the VB-2 vault back into the B/D line and began draining the blowdown piping to facilitate work on VB-2.
November 7, 2000   11:30 Braidwood RP received information that the leak may have occurred for a period of 7-10 days and that the water that leaked was from the circulating water blowdown line, which carries the liquid radiological discharges from the station to the river.
November 7, 2000 11:30 Braidwood RP received information that the leak may have occurred for a period of 7-10 days and that the water that leaked was from the circulating water blowdown line, which carries the liquid radiological discharges from the station to the river.
November 7, 2000   12:00
November 7, 2000 12:00
* After the CW B/D line had drained sufficiently, the entire VB-2 isolation valve and vacuum breaker assembly was replaced.
* After the CW B/D line had drained sufficiently, the entire VB-2 isolation valve and vacuum breaker assembly was replaced.
104
104 2
 
Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)
Attachment 12 Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)
Event Timeline Page8of 13 a November 7, 2000 12:30 A decision was made to initiate soil sampling in the vicinity of the vacuum breaker structure, and to obtain a water sample from the standing water that was onsite, but near the Smiley Road ditch.
Event Timeline Page8of 13a November 7, 2000   12:30
November 7, 2000 13:00 Braidwood RP Manager and Station Manager discuss and agree to additional sampling.
* A decision was made to initiate soil sampling in the vicinity of the vacuum breaker structure, and to obtain a water sample from the standing water that was onsite, but near the Smiley Road ditch.
November 7, 2000 13:00
* Braidwood RP Manager and Station Manager discuss and agree to additional sampling.
Plan was approved.
Plan was approved.
November 7, 2000 18:00
November 7, 2000 18:00 Braidwood management talked with local residents to explain the issue.
* Braidwood management talked with local residents to explain the issue.
November 7, 2000 19:00 The results of the samples from November 7, 2000, were discussed with corporate Generation Support Department (GSD) RP Manager. Corporate GSD agreed to discuss the issue with the corporate GSD General Manager.
November 7, 2000 19:00
November 7, 2000 19:45 The Station Manager and Site Vice-President (VP) were notified of the sample results. A total of 5 soil samples were obtained within approximately 30 feet of the vacuum breaker VB-2 structure, and 2 of the 5 soil samples had detectable levels of radioactivity. The onsite soil sample obtained near the Smiley Road ditch was analyzed indicated no gamma radioactivity, and water analysis from the location indicated tritium at 35,000 pCi/L.
* The results of the samples from November 7, 2000, were discussed with corporate Generation Support Department (GSD) RP Manager. Corporate GSD agreed to discuss the issue with the corporate GSD General Manager.
November 7, 2000 21:15 Circ water blowdown is restored.
November 7, 2000 19:45
105 2
* The Station Manager and Site Vice-President (VP) were notified of the sample results. A total of 5 soil samples were obtained within approximately 30 feet of the vacuum breaker VB-2 structure, and 2 of the 5 soil samples had detectable levels of radioactivity. The onsite soil sample obtained near the Smiley Road ditch was analyzed indicated no gamma radioactivity, and water analysis from the location indicated tritium at 35,000 pCi/L.
Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)
November 7, 2000 21:15
* Circ water blowdown is restored.
105
 
Attachment 12 Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)
Event Timeline Page9of 13 November 8, 2000 08:30
Event Timeline Page9of 13 November 8, 2000 08:30
* The Braidwood RP Manager discussed the sample results on the morning call.
* The Braidwood RP Manager discussed the sample results on the morning call.
November 8, 2000 14:00
November 8, 2000 14:00
* The Braidwood RP Manager, Chemistry Manager, Regulatory Assurance Manager, Station Manager, and Site VP met to discuss the current status, next steps, and sampling for the event.
* The Braidwood RP Manager, Chemistry Manager, Regulatory Assurance Manager, Station Manager, and Site VP met to discuss the current status, next steps, and sampling for the event.
November 8, 2000 16:00 Additional onsite sampling of the standing water in the area leading to the Smiley Road ditch was performed. Four water samples were taken and results indicated tritium levels ranging from 35,000 to 53,000 pCi/L. No gamma isotopic activity was detected in the water.
November 8, 2000 16:00 Additional onsite sampling of the standing water in the area leading to the Smiley Road ditch was performed. Four water samples were taken and results indicated tritium levels ranging from 35,000 to 53,000 pCi/L.
November 8, 2000 18:00
No gamma isotopic activity was detected in the water.
* Conference call between site and corporate regarding test results and proposed actions.
November 8, 2000 18:00 Conference call between site and corporate regarding test results and proposed actions.
November 9, 2000 10:00 A conference call was held with the Site Management and Corporate Personnel to finalize and approve an Offsite Sampling Plan, a Remediation Plan, and a Communications Plan. At 12:00, discussions were held with site and regional NRC personnel. At 1210, notification of the offsite release was made to Will County authorities and to the Reed Township Highway Commissioner. At 12:45, RP was dispatched to obtain water samples from the Smiley Road ditch.
November 9, 2000 10:00 A conference call was held with the Site Management and Corporate Personnel to finalize and approve an Offsite Sampling Plan, a Remediation Plan, and a Communications Plan.
106
At 12:00, discussions were held with site and regional NRC personnel. At 1210, notification of the offsite release was made to Will County authorities and to the Reed Township Highway Commissioner.
 
At 12:45, RP was dispatched to obtain water samples from the Smiley Road ditch.
Attachment 12 Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)
106 2
Event Timeline Page 10 of 13 November 9, 2000     14:00 Four water samples were obtained from the Smiley Road ditch. Gamma isotopic analysis indicated and the tritium analyses ranged from 19,000 pCi/L to 25,000 pCi/L NQPF.
Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)
Event Timeline Page 10 of 13 November 9, 2000 14:00 Four water samples were obtained from the Smiley Road ditch. Gamma isotopic analysis indicated and the tritium analyses ranged from 19,000 pCi/L to 25,000 pCi/L NQPF.
Teledyne Isotopes Midwest Laboratory also analyzed these samples with similar results.
Teledyne Isotopes Midwest Laboratory also analyzed these samples with similar results.
November 9, 2000 17:30
November 9, 2000 17:30 The NRC Regional Office and Illinois Department of Nuclear Safety (IDNS) were notified of the Smiley Road ditch sample analyses results.
* The NRC Regional Office and Illinois Department of Nuclear Safety (IDNS) were notified of the Smiley Road ditch sample analyses results.
November 10, 2000 01:00 IDNS came to the site to take (4) samples from the Smiley Road ditch.
November 10, 2000 01:00
November 10, 2000 11:00 Pumping of the water back to the blowdown line commenced. Pumping continued using a 600 gpm pump, approximately 18 hours per day.
* IDNS came to the site to take (4) samples from the Smiley Road ditch.
November 10, 2000 11:00
* Pumping of the water back to the blowdown line commenced. Pumping continued using a 600 gpm pump, approximately 18 hours per day.
* Corporate led remediation team formed and OP-AA-101-503 "NGG Issue Management Worksheet" was entered. Attachment 2 (action plan) of this procedure was created and approved.
* Corporate led remediation team formed and OP-AA-101-503 "NGG Issue Management Worksheet" was entered. Attachment 2 (action plan) of this procedure was created and approved.
November 2000 Spill Conclusions In 2000, VB-2 failed and released approximately three million gallons to the Braidwood Station grounds. A local resident observed and reported the spill to the Illinois Environmental Protection Agency (IEPA), who in turn notified the Braidwood Station National Pollutant Discharge Elimination System (NPDES) Coordinator. The NPDES Coordinator wrote PIF A2000-04281 and notified the Illinois Department of Nuclear Safety (IDNS), the Illinois Emergency Management Agency (IEMA) and Braidwood Senior Management. The Braidwood Radiation Protection (RP) Manager and the RP Technical Superintendent discussed the need to collect samples of available water at VB-2. The sample results indicated >20,000 pCi/L tritium was present in the spilled water. The immediate response to this event was to shutdown the blowdown system, repair the valve as soon as possible, and engage Senior Corporate Management to create a spill response plan.
November 2000 Spill Conclusions In 2000, VB-2 failed and released approximately three million gallons to the Braidwood Station grounds. A local resident observed and reported the spill to the Illinois Environmental Protection Agency (IEPA), who in turn notified the Braidwood Station National Pollutant Discharge Elimination System (NPDES) Coordinator. The NPDES Coordinator wrote PIF A2000-04281 and notified the Illinois Department of Nuclear Safety (IDNS), the Illinois Emergency Management Agency (IEMA) and Braidwood Senior Management. The Braidwood Radiation Protection (RP) Manager and the RP Technical Superintendent discussed the need to collect samples of available water at VB-2. The sample results indicated >20,000 pCi/L tritium was present in the spilled water.
107
The immediate response to this event was to shutdown the blowdown system, repair the valve as soon as possible, and engage Senior Corporate Management to create a spill response plan.
 
107 2
Attachment 12 Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)
Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)
Event Timeline Page 11 of 13 A Senior Corporate Manager was chosen to assemble and direct an Issues Management Team (IMT). Although knowledgeable personnel supported the IMT, there was no integrated procedure in place to ensure that all necessary actions were completed (Root Cause 3). As a result, the groundwater tritium was not properly characterized and remediated.
Event Timeline Page 11 of 13 A Senior Corporate Manager was chosen to assemble and direct an Issues Management Team (IMT).
Although knowledgeable personnel supported the IMT, there was no integrated procedure in place to ensure that all necessary actions were completed (Root Cause 3). As a result, the groundwater tritium was not properly characterized and remediated.
The IMT entered four (4) Corporate procedures, which provide guidance to identify, evaluate, remediate and communicate the radiological concerns. The four (4) procedures were:
The IMT entered four (4) Corporate procedures, which provide guidance to identify, evaluate, remediate and communicate the radiological concerns. The four (4) procedures were:
* NSP-RP-61 01, "10 CFR 50. 75(g)(1) Documentation Requirements" 0   CWPI-NSP-1 -1, "CAP Process Manual of Common Work Practice Instructions -
NSP-RP-61 01, "10 CFR 50. 75(g)(1) Documentation Requirements" 0 CWPI-NSP-1 -1, "CAP Process Manual of Common Work Practice Instructions -
Instruction on Event Response Guidelines'
Instruction on Event Response Guidelines' OP-AA-1 01-501, "NGG Significant Event Reporting' 0 OP-AA-1 01-503, "NGG Issues Managemenf'.
* OP-AA-1 01-501, "NGG Significant Event Reporting' 0   OP-AA-1 01-503, "NGG Issues Managemenf'.
However, no historical documentation could be located to demonstrate that the procedures (other than NSP-RP-61 01) were fully executed. There is no evidence of the use of Passport for the documentation of the IMT plans and activities as required by OP-AA-101-503, "NGG Issues Management". This root cause team interviewed (by telephone) the Corporate Senior Manager who was assigned to manage the Issues Management Team. He was questioned concerning the execution of the IMT's responsibilities. The Corporate Senior Manager had little recollection of the details of the team's response.
However, no historical documentation could be located to demonstrate that the procedures (other than NSP-RP-61 01) were fully executed. There is no evidence of the use of Passport for the documentation of the IMT plans and activities as required by OP-AA-101-503, "NGG Issues Management". This root cause team interviewed (by telephone) the Corporate Senior Manager who was assigned to manage the Issues Management Team. He was questioned concerning the execution of the IMT's responsibilities. The Corporate Senior Manager had little recollection of the details of the team's response. Although that Corporate Senior Manager had the responsibility to manage the IMT's completion of characterization and remediation plans and would normally be held accountable, he is no longer employed by Exelon. This indicates weak management review and oversight of spill response activities. (Root Cause 4)
Although that Corporate Senior Manager had the responsibility to manage the IMT's completion of characterization and remediation plans and would normally be held accountable, he is no longer employed by Exelon. This indicates weak management review and oversight of spill response activities. (Root Cause 4)
The IMT developed separate soil sampling plans and water sampling plans flowcharts (decision trees). For soil, all documentation was done within the station 10 CFR 50.75(g) procedure, NSP-RP-6101. For water, the sampling plan included a review of the tritium in the water and implementation of a Remediation/Control Plan. Notes on the water sampling plan indicate that the team considered: 1) pumping the water back into the blowdown line and 2) well monitoring.
The IMT developed separate soil sampling plans and water sampling plans flowcharts (decision trees).
The IMT had also recognized the need to evaluate local hydrology for potential impact of the tritiated spill in groundwater as referenced in a contractor's proposal for the implementation of a Stage 1 and Stage 2 plan. Stage 1 included the installation of wells to assess the local hydrology to determine groundwater gradients and movement . This stage of the plan was executed by the IMT. Stage 2 of the plan included sampling of the groundwater to determine mixing model and surface infiltration into an aquifer. Stage 2 of the plan was not executed.
For soil, all documentation was done within the station 10 CFR 50.75(g) procedure, NSP-RP-6101.
For water, the sampling plan included a review of the tritium in the water and implementation of a Remediation/Control Plan. Notes on the water sampling plan indicate that the team considered: 1) pumping the water back into the blowdown line and 2) well monitoring.
The IMT had also recognized the need to evaluate local hydrology for potential impact of the tritiated spill in groundwater as referenced in a contractor's proposal for the implementation of a Stage 1 and Stage 2 plan.
Stage 1 included the installation of wells to assess the local hydrology to determine groundwater gradients and movement.
This stage of the plan was executed by the IMT. Stage 2 of the plan included sampling of the groundwater to determine mixing model and surface infiltration into an aquifer. Stage 2 of the plan was not executed.
The water was pumped back into the B/D line on 11/10/00 and hydrology wells were installed in the area of the 2000 leak to characterize the local hydrology. The contractor report specified that the groundwater in the area of VB-2 would take 15 years to travel the 800 feet to reach the property line.
The water was pumped back into the B/D line on 11/10/00 and hydrology wells were installed in the area of the 2000 leak to characterize the local hydrology. The contractor report specified that the groundwater in the area of VB-2 would take 15 years to travel the 800 feet to reach the property line.
108
108 2
 
Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)
Attachment 12 Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)
Event Timeline Page 12 of 13 The report then clarifies that the flow velocity would not apply to the surface water that apparently flowed from the valve box, over the land surface, and to the ditch along the road.
Event Timeline Page 12 of 13 The report then clarifies that the flow velocity would not apply to the surface water that apparently flowed from the valve box, over the land surface, and to the ditch along the road.
The remediation efforts were halted after the surface water was pumped back into the B/D line Although no documentation exists for the basis behind the decision to not perform groundwater sampling, a review of IMT data and, notes has lead the Root Cause Investigation Team to Conclude that the following information was considered in the decision making process:
The remediation efforts were halted after the surface water was pumped back into the B/D line Although no documentation exists for the basis behind the decision to not perform groundwater sampling, a review of IMT data and, notes has lead the Root Cause Investigation Team to Conclude that the following information was considered in the decision making process:
* The spilled water had already been approved for release. Therefore, it was already determined to meet concentration limits for release to the public. The team assessed the impact of the radiological spill against known reporting requirements. The Illinois Groundwater statute was absent from the list in the IMT notes (Causal Factor 4).
The spilled water had already been approved for release. Therefore, it was already determined to meet concentration limits for release to the public. The team assessed the impact of the radiological spill against known reporting requirements. The Illinois Groundwater statute was absent from the list in the IMT notes (Causal Factor 4).
* The hydrology study indicated that it would be. 15 years before groundwater in the area of VB-2 would migrate offsite to potentially impact offsite drinking water wells. At that rate, the tritium concentration would be below drinking water standards, potentially even below detectable levels, by the time it reached the site boundary due to radiological decay and, potentially, dilution. [Today, hydrology experts state that once the tritium enters the groundwater, dilution does not significantly occur.]
* The hydrology study indicated that it would be. 15 years before groundwater in the area of VB-2 would migrate offsite to potentially impact offsite drinking water wells. At that rate, the tritium concentration would be below drinking water standards, potentially even below detectable levels, by the time it reached the site boundary due to radiological decay and, potentially, dilution. [Today, hydrology experts state that once the tritium enters the groundwater, dilution does not significantly occur.]
Further efforts included a 10 CFR 50.75(g) characterization study. The 2000 10 CFR 50.75(g) focused primarily on soil sampling. The 10 CFR 50.75(g) study does reference the tritium concentrations that were found in the standing water. The 10 CFR 50.75(g) study did not direct groundwater sampling for tritium nor assess the environmental impact of the spilled tritium (Failed Barrier 3). The 2000 RCR Team required an analysis of the 2000 leak 10 CFR 50.75(g) by an independent Certified Health Physicist and approval by Braidwood Senior Management, however, this analysis did not include tritium. As a result, the groundwater tritium went undetected until the 2005 tritium sampling discovered it. This indicates weak management review and oversight of spill response activities. (Root Cause 4)
Further efforts included a 10 CFR 50.75(g) characterization study. The 2000 10 CFR 50.75(g) focused primarily on soil sampling.
The year 2000 leak from Vacuum Breaker (VB) 2, RCR # 38237 documented 5 CW B/D vacuum breaker spills. Two of these released a large volume of water. The root-cause of these leaks was inadequate preventative maintenance programs and inadequate design configuration (Root Cause 1). Effectiveness Review (EFR) of the Corrective Actions to Prevent Recurrence (CAPRs) of large volume leaks determined that the CAPRs were effective at resolving the Root Cause. However, the Root Cause was narrowly defined, only evaluating the large volume valve leaks and not considering radiological impacts from the spills due to a lack of technical rigor (CAPR 3 and CAPR 5 address this issue).
The 10 CFR 50.75(g) study does reference the tritium concentrations that were found in the standing water. The 10 CFR 50.75(g) study did not direct groundwater sampling for tritium nor assess the environmental impact of the spilled tritium (Failed Barrier 3). The 2000 RCR Team required an analysis of the 2000 leak 10 CFR 50.75(g) by an independent Certified Health Physicist and approval by Braidwood Senior Management, however, this analysis did not include tritium.
109
As a result, the groundwater tritium went undetected until the 2005 tritium sampling discovered it. This indicates weak management review and oversight of spill response activities. (Root Cause 4)
 
The year 2000 leak from Vacuum Breaker (VB) 2, RCR # 38237 documented 5 CW B/D vacuum breaker spills. Two of these released a large volume of water. The root-cause of these leaks was inadequate preventative maintenance programs and inadequate design configuration (Root Cause 1).
Attachment 12 Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)
Effectiveness Review (EFR) of the Corrective Actions to Prevent Recurrence (CAPRs) of large volume leaks determined that the CAPRs were effective at resolving the Root Cause. However, the Root Cause was narrowly defined, only evaluating the large volume valve leaks and not considering radiological impacts from the spills due to a lack of technical rigor (CAPR 3 and CAPR 5 address this issue).
109 2
Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)
Event Timeline Page 13 of 13 The 2000 Root Cause Report (RCR) Team discovered the large volume 1998 VB-3 leak and wrote PIF A2000-04281 to have the 1998 spill reviewed per procedure # NSP-RP-6101 for residual radioactivity under 10 CFR 50.75(g). The soil sampling conducted as part of the 10 CFR 50.75(g) process indicated similar deposited radionuclides in the soil as that found during the 2000 leak. However, tritium was not addressed (Failed Barrier 3).
Event Timeline Page 13 of 13 The 2000 Root Cause Report (RCR) Team discovered the large volume 1998 VB-3 leak and wrote PIF A2000-04281 to have the 1998 spill reviewed per procedure # NSP-RP-6101 for residual radioactivity under 10 CFR 50.75(g). The soil sampling conducted as part of the 10 CFR 50.75(g) process indicated similar deposited radionuclides in the soil as that found during the 2000 leak. However, tritium was not addressed (Failed Barrier 3).
Braidwood Senior Management and Exelon Corporate Senior Management did not track characterization and mitigation plans to completion during and following the year 2000 spill.
Braidwood Senior Management and Exelon Corporate Senior Management did not track characterization and mitigation plans to completion during and following the year 2000 spill.
Although the 2000 Annual Effluent Report did report the 2000 vacuum breaker leakage as an unplanned release, it did not contain a proper assessment of the dose to the public. The 1998 Annual Effluent Report was not amended to report the 1998 vacuum breaker leakage (discovered in 2000) and associated dose to the public (IR 455079) & (CA-15).
Although the 2000 Annual Effluent Report did report the 2000 vacuum breaker leakage as an unplanned release, it did not contain a proper assessment of the dose to the public. The 1998 Annual Effluent Report was not amended to report the 1998 vacuum breaker leakage (discovered in 2000) and associated dose to the public (IR 455079) & (CA-15).
HU-AA-102 and -1212, Technical Human Performance Practices and Technical Task Risk/Rigor Assessment, Pre-Job Brief, Independent Third Party Review, and Post-Job Brief procedures have been instituted to improve technical rigor, questioning attitude, and attention to detail (CAPR 3). OP-AA-106-101-1002, Exelon Nuclear Issues Management, will be revised to: 1) improve Corrective Action Program (CAP) controls of Issue Management Teams, 2) utilize the tools and techniques of the Exelon HU-AA-102 and -1212, Technical Human Performance Practices and Technical Task Risk/Rigor Assessment, Pre-Job Brief, Independent Third Party Review, and Post-Job Brief procedures, 3) strengthen reporting requirements to station Senior Management, and 4) define station Senior Management responsibilities oversight and challenge of events and issues from initiation to final disposition (CAPR 5).
HU-AA-102 and -1212, Technical Human Performance Practices and Technical Task Risk/Rigor Assessment, Pre-Job Brief, Independent Third Party Review, and Post-Job Brief procedures have been instituted to improve technical rigor, questioning attitude, and attention to detail (CAPR 3). OP-AA-106-101-1002, Exelon Nuclear Issues Management, will be revised to: 1) improve Corrective Action Program (CAP) controls of Issue Management Teams, 2) utilize the tools and techniques of the Exelon HU-AA-102 and -1212, Technical Human Performance Practices and Technical Task Risk/Rigor Assessment, Pre-Job Brief, Independent Third Party Review, and Post-Job Brief procedures, 3) strengthen reporting requirements to station Senior Management, and 4) define station Senior Management responsibilities oversight and challenge of events and issues from initiation to final disposition (CAPR 5).
An email from an RP supervisor who attended an exit meeting for an NRC REMP (radiological effluent monitoring program) inspection (NRC Inspection Report Braidwood 2001-0005) provided the following information. The Nuclear Regulatory Commission (NRC) reviewed the 2000 Root Cause (RC 38237) (documented in NRC Inspection Report Braidwood 2001-0005) and had a recommendation to sample residential wells in the area of concern "just to see negative results from these locations to support future cleanup activities" (documented only in the email). A second comment from the NRC review was that the root cause only focused on the equipment issues and not on spill recovery aspects. No documentation could be found to show that the Issues Management Team or Braidwood Senior Management reacted to these NRC's observations. This response reflects a weak management review and oversight of spill response activities (Root Cause 4). A contributing cause to this overall event was a weak questioning attitude and an inadequate challenge culture by Braidwood Senior Management regarding the 17 CW B/D leaks over the 10 year period bridging 1996 to the present.
An email from an RP supervisor who attended an exit meeting for an NRC REMP (radiological effluent monitoring program) inspection (NRC Inspection Report Braidwood 2001-0005) provided the following information. The Nuclear Regulatory Commission (NRC) reviewed the 2000 Root Cause (RC 38237) (documented in NRC Inspection Report Braidwood 2001-0005) and had a recommendation to sample residential wells in the area of concern "just to see negative results from these locations to support future cleanup activities" (documented only in the email). A second comment from the NRC review was that the root cause only focused on the equipment issues and not on spill recovery aspects. No documentation could be found to show that the Issues Management Team or Braidwood Senior Management reacted to these NRC's observations. This response reflects a weak management review and oversight of spill response activities (Root Cause 4).
A contributing cause to this overall event was a weak questioning attitude and an inadequate challenge culture by Braidwood Senior Management regarding the 17 CW B/D leaks over the 10 year period bridging 1996 to the present.
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Latest revision as of 02:52, 14 January 2025

Root Cause Report, Inadequate Response to Unplanned Environmental Tritium Releases from Braidwood Station Due to Weak Management Oversight and the Lack of Integrated Procedural Guidance
ML102600357
Person / Time
Site: Braidwood  Constellation icon.png
Issue date: 11/30/2005
From:
- No Known Affiliation
To:
Office of Information Services
References
428868, FOIA/PA-2010-0209
Download: ML102600357 (109)
v • d • e


Text

6-,,e,ýOA liýýO+ eAU44-1 ROOT CAUSE REPORT TITLE:

Inadequate response to unplanned environmental tritium releases from Braidwood Station due to weak managerial oversight and the lack of integrated procedural guidance.

Braidwood Units 1 and 2 Unit(s):

Event Date:

Event Time:

11/30/2005 11:50 428868 02/14/06 Action Tracking Item Number:

Report Date:

Sponsoring Manager:

I Janice Kuczynski Investigators:

"Jason Eggart

'Tom Leffler Randy Kalb Kim Aleshire Glen Vickers Scott Kirkland Jim Crawford Mike Miller Jeff Burkett Dan Stroh Carl Dunn

/

Position Braidwood Chemistry Lead Investigator Root Cause (RC) Qualified Investigator Dresden Chemistry Investigator Braidwood EP (ODCM) Investigator LaSalle RP Investigator Quad Cities Investigator BWD CMO RC Qualified Investigator Braidwood Operations Braidwood Operations Braidwood Engineering Senior Mentor I

Executive Summary:

Reason for Investigation:

Braidwood Station identified low levels of elevated tritium in the groundwater on and in the vicinity of Braidwood Station property (See Attachment 7 for Map).

The presence of these elevated levels exceeds levels specified in Illinois EPA regulations (Attachment 10).

The Illinois Environmental Protection Agency (IEPA) groundwater limit for tritium concentration parallels the Federal EPA regulation for annual radiation limits due to drinking water radioactivity. The statutes imply that four (4) mrem would not be exceeded if less than two liters of water at the IEPA limit were.:.

ingested daily for a year. In addition, the U.S. Nuclear Regulatory Commission (NRC) provides limnits on liquid effluent releases and how those effluents must be

monitored and reported.

The NRC has reached a preliminary conclusion that Braidwood may not have satisfied all associated regulations in this regard. When the inspection exit for the current NRC review is completed, any potential violations will be entered into the Braidwood Corrective Action Process.

This report provides insights on the causes of these potential violations and associated corrective actions. Additional investigation will be performed commensurate with the content of any such potential violations.

Scope of the Review:

The first focus of this root cause investigation is to determine the root cause(s) of and appropriate corrective actions for the unplanned tritium releases from Braidwood Station (See Attachment 1). The Braidwood Tritium Remediation Team has responsibility under Action Request (AR) 435383 for corrective actions to prevent future unplanned tritium releases to the environment and to remediate the existing condition of detectable tritium in groundwater on and in the vicinity of Braidwood Station property. The second focus of this root cause team is to evaluate the effectiveness of Braidwood's response to the Circulating Water (CW) Blowdown (BID) leaks, which deposited tritiated water on the ground during 1998 and 2000 as well as during the smaller volume leaks, which both preceded and succeeded the 1998 and 2000 leaks. If this investigation determines that Braidwood's response actions were not effective, this root cause team will determine the root cause(s) and appropriate corrective actions for those ineffective response actions.

Root Causes and Corrective Actions to Prevent Recurrence (CAPRs):

The root cause of the large volume leaks in 1998 and 2000 is documented in Root Cause Report (RCR) 38237, which determined that the Circulating Water (CW)

Blowdown (B/D) Vacuum Breaker (VB) Valves had inadequate preventative maintenance programs and inadequate design configuration (Root Cause 1). The Corrective Actions to Prevent Recurrence (CAPRs) from RCR 38237 were to institute a Preventative Maintenance Program and system modifications, which are complete and have been verified to be effective in preventing major vacuum breaker valve failures that resulted in large volume spills (CAPR 1). The root cause of the small tritiated water leaks, which both preceded and succeeded the 1998 and 2000 leaks, was that the need for a near zero leakage standard was not identified due to a then-existing lack of Technical Rigor/Questioning Attitude (Root Cause 2). The Braidwood Tritium Remediation Team will determine the methodology and implement the plan for future radiological releases, including leakage standards under IR 435383 and effectiveness review ATI# 428868 (CAPR 2). HU-AA-102 and HU-AA-1212, Technical Human Performance Practices and Technical Task Risk/Rigor Assessment, Pre-Job Brief, Independent Third Party Review, and Post-Job Brief procedures have been instituted to improve technical rigor, questioning attitude, and attention to detail (CAPR 3).

2

This Root Cause Team determined that Braidwood's response to the 1998 and 2000 events was ineffective. The response to the 1998 and 2000 releases of radioactivity (tritium) to an unplanned location is indicative of ineffective corrective actions. As directed by the root cause charter (Attachment 1), these ineffective corrective actions are addressed in this root cause report.

The first root cause for the ineffective response was a lack of integrated procedural guidance to ensure proper recognition, evaluation, and timely mitigation of the radiological spill events (Root Cause 3). Integrated procedures will be developed and implemented to provide detailed spill and leak response requirements which will ensure full compliance with 3

State and Federal laws and regulations and to integrate Exelon resources to respond to radiological leaks and spills (CAPR 4). A second root cause for the ineffective response was weak management review and oversight of spill response activities (Root Cause 4).

Specifically, management had a weak questioning attitude and an inadequate challenge culture regarding the 17 CW B/D leaks over the 10 year period bridging 1996 to 2006. Exelon Corporate, the Issues Management Team, and Braidwood Senior Management did not track characterization and mitigation plans to completion during and following the year 2000 spill. HU-AA-102 and HU-AA-1212, Technical Human Performance Practices and Technical Task Risk/Rigor Assessment, Pre-Job Brief, Independent Third Party Review, and Post-Job Brief procedures have been instituted to improve technical rigor, questioning attitude, and attention to detail (CAPR 3).

OP-AA-106-101-1002, Exelon Nuclear Issues Management, will be revised to: 1) improve Corrective Action Program (CAP) controls of Issues Management teams, 2) utilize the tools and techniques of the Exelon HU-AA-102 and HU-AA-1212, Technical Human Performance Practices and Technical Task Risk/Rigor Assessment, Pre-Job Brief, Independent Third Party Review, and Post-Job Brief procedures, 3) strengthen reporting requirements to station Senior Management, and 4) define station Senior Management responsibilities for oversight and challenge of events and issues from initial identification to final disposition (CAPR 5).

Extent of Condition:

Exelon Nuclear is evaluating the potential for unplanned tritium releases at each of its facilities, with added emphasis on Pressurized Water Reactors due to tritium production rates. Nuclear Event Report (NER 428868-12) will require all Exelon Sites to take actions to research historical spills and determine if tritium remediation is required. The nuclear industry will be informed of the issue through a Nuclear Network Operating Experience Report (NNOE 428868-13).

Other spill type (Hazardous Material) response procedures were reviewed and determined to have effective guidance through the Hazmat and Environmental programs (Attachments 2

& 8).

These programs and procedures will receive further review and update to integrate radiological interfaces (CAPR 3).

4

Risk Assessment/ Reportability:

The Nuclear Safety Risk Assessment showed no impact on station operation or response to postulated accident conditions.

The event was reportable under Reportability Manual, SAF 1.9, News Release or Notification of Other Government Agencies per 10 CFR 50.73.

Previous Events:

Since 1996, 17 CW B/D valve leaks were noted in the Braidwood Corrective Action Database and Work Control System as documented in Table 1 of this report in the Events Description Section.

Responses varied from a request for a normally scheduled repair to immediate remediation efforts.

The best response, which occurred in year 2000, removed water from the spill area, but did not effectively determine the extent of condition for full remediation.

Condition Statement:

In response to an Illinois Environmental Protection Agency (IEPA) inquiry in March 2005, Braidwood Station began taking a series of groundwater samples within Braidwood Station property boundaries. Some of those samples identified elevated levels of tritium in the Braidwood Station groundwater. Issue Report (IR) # 328451 documented these monitoring results in April 2005. This sampling continued over a period of eight months.

In response to the results of these initial and follow-up monitoring samples, an Issues Management Team was formed on November 30, 2005 in accordance with Exelon procedure OP-AA-106-101-1002. Additional sampling resulted in elevated tritium levels being identified in groundwater in the vicinity of Circulating Water (CW)

Blowdown (B/D) system Vacuum Breakers (VB) #2 and CW B/D VB #3, which had experienced large volume leaks in 1998 [(VB 3) Problem Identification Form (PIF) #

Al 998-04324] and in 2000 [(VB 2) I R # 38237].

On 30 November 2005, the Issues Management Team (IMT) initiated IR# 428868 reporting that elevated levels of tritium had been detected in onsite groundwater sampling wells and triggering this root cause investigation and report. Subsequent sampling identified elevated tritium levels outside Braidwood Station property boundaries.

On 16 December 2005, the Illinois Environmental Protection Agency (IEPA) issued Violation Notice W-2005-00537 to Exelon Generation - Braidwood Station, alleging Impairment of Resource Groundwater.

See Attachment 6 for an overview of the Circulating Water (CW) Blowdown (B/D)

System operation. See Attachment 7 for a map of the affected areas.

5

Event

Description:

Braidwood Station identified elevated levels of tritium in the groundwater that exceed Illinois EPA regulations (Attachment 10). Due to the extended period of time and the number of events covered in this root cause investigation, the timeline became very complex. For clarity, the Event Description has been organized as follows:

The Events and Causal Factors (E&CF) Chart has been placed in Attachment 4.

Page 1 of 3 of the E & CF chart depicts the timeline for all vacuum breaker issues.

Page 2 of 3 and page 3 of 3 depict barrier analysis of the events on VB-2 and VB-3.

Displayed in this event description section are:

a.

Table 1, Circulating Water (CW) Blowdown (B/D) Leak Table, which details the leaks that have been identified during this investigation.

b.

Event timeline summary with events that led up to this Root Cause Investigation.

1. 2, CW B/D VB-2 and VB-3 detailed timelines.
a.

Leaks that are within the scope of this investiqation The elevated levels of tritium have been determined to have originated from historical spills from the CW B/D system. Since 1996, 17 CW B/D vacuum breaker leaks were noted in the Braidwood Corrective Action Database and work control database.

The following table is a summary of leaks identified from records, including the station's response.

This team did not locate any computerized records of the Work Orders or Problem Identification Forms (PIFs) prior to approximately 1996. As such, the quantification of and response to these events had to be recreated from historical documents and interviews of involved personnel. Two means of identifying the impact of potential leaks from initial plant operation in 1988 to 1996 were considered. The first was to pull microfiche records for review and the second was to perform direct characterization of the conditions in the vicinity of all of the Circulating Water (CW)

Blowdown (B/D) Vacuum Breakers (VBs).

Because of the need to have full confidence in the characterization of conditions in the vicinity of the vacuum breakers, the decision was made to install both deep and shallow monitoring wells in the vicinity of all of the CW B/D vacuum breakers. This was determined to be preferable to depending on locating microfiche records for possible leaks and monitoring only those locations.

6

Table 1: CW BID Leak Table

RESPONSE

PIF/

Immediate Particulate Tritium 10 CFR Date Event Leak Size WR CRAIR Action Sample Sample 50.75(g)

Resolution l

11/27/96 VB-1

-250,000 WO,

'rocess had Requested No 1996 No 1996 No 1996 06/19/97 1" pipe to air leak gals 96111970 personnel repair.,

documents documents documents release valve broke.

decide found.

found.

found.

Tritium plume was WR or Will be Tritium Will be identified around VB-I PIP. So,Reeito oPIF, WR addressed plume was addressed in 2006. Remediation only.

under ATI# identified in under ATI# being addressed under 435383 2006. Will 435383 IR# 435383.

be addressed under ATI#

_435383 2

1/5/98 VB-2 leak Small leak.

WR#

1rocess had Requested No 1998 No 1998 No 1998 11/08/00 replaced the 98000682 personnel repair documents documents documents float, replaced vacuum decide found.

found.

found.

breaker and isolation WR or Will be Tritium Will be valve. Tritium plume PIF. So, addressed plume was addressed was identified around o l WR under ATI# identified in under ATI# VB-2 in 2005.

only.

435383 2005. Will 435383 Remediation being be addressed addressed under IR#

under ATI#

435383.

435383 3

12/4/98 VB-3 Caused WO A1998-Isolated 04/26/01 No 1998 07/25/01 05/20/02 1" pipe to the leak - seat flooding. -

98127749 04324 air release Soil documents evaluation air release valve broke 3M gals valve until Particulate found.

detected due to corrosion. Guide

  • parts radioactivity Tritium particulate post sheared weld off could be above plume was radioactivity, float. Entire vacuum received, background. identified in breaker replaced (July This 2005. Will 2001). Tritium plume stopped be addressed was identified around this under ATI#

VB-3 in 2005.

leakage.

435383 Remediation being addressed under IR#

_435383.

4 11/6/00 VB-2 Caused WO A2000-Replaced Particulate Tritium Yes.

11/06/00 Float broke on leak-flooding. -

98003276 04281 vacuum radioactivity plume was Sampling vacuum breaker. Tritium seat 3M gals Root breaker above identified detected plume was identified Cause background. around VB-2 particulate around VB-2 in 2005.

38237 in 2005.

radioactivity. Remediation being Will be addressed under IR#

addressed 435383.

under ATI#

435383 5

11/10/00 VB-6 Small leak WO None.

Requested No 2000 No 2000 No 2000 10/17/05 Valve leak 99231846 IR should repair.

documents documents documents assembly replaced. 2006 have been found.

found, found.

remediation sampling seat written.

Will be 2006 Will be showed no tritium in the addressed samples addressed groundwater at this under ATI#

show no under ATI#

location.

435383 tritium in the 435383 groundwater_

7

RESPONSE

PIF/

Immediate Particulate Tritium 10 CFR Date Event Leak Size WR CR/IR Action Sample Sample 50.75(g)

Resolution 6

11/20/00 VB-1 Vacuum WO None.

Rebuilt 11/20/00 Tritium Yes.

11/21/00 Rebuilt valve leak breaker 99233404 IR

valve, samples sampling Sampling internals. Tritium lifting.

should reported was reported plume was identified have negative for performed negative for around VB-1 in 2006.

been detectable no detectable detectable Remediation being written.

radioactivity, activity.

radioactivity addressed under IR#

1_

435383.

7 6/18/01 VB-3 1/2 GPH leak WO 4,2001-Sampled No 2001 Tritium No 2001 05/20/02 Rebuilt leak from main 98127749 01806

water, documents plume was documents valve. Tritium plume vacuum found.

identified found.

was identified around breaker.

Will be around VB-3 Will be VB-3 in 2005.

addressed in 2005. Will addressed Remediation being under ATI# be addressed under ATI# addressed under IR#

435383 under ATI#

435383 435383.

435383.

8 6/18/01 VB-9 Water in N/A A2001-Sampled Negative for No 2001 No 2001 No active leak.

vault.

01806

water, detectable documents documents Attributed to particulate found. No found.

groundwater, 2006 adioactivity.

tritium in 2006 remediation sampling groundwater remediation showed no tritium in at this sampling the groundwater at this location showed no location.

reported in tritium.

2006.

9 6/18/01 VB-10 Water in N/A A2001-Sampled Negative for No 2001 No 2001 No active leak.

vault 01806

water, detectable documents documents Attributed to particulate found. No
found, groundwater. 2006 radioactivity.

tritium in Will be remediation sampling groundwater addressed showed no tritium in at this under ATI# the groundwater at this location in 435383 location.

2006.

10 6/18/01 VB-11 Water in N/A A2001-Sampled No 2001 No 2001 No 2001 No active leak.

vault 01806 water.

documents documents documents Attributed to

found, found. No found.

groundwater. 2006 Will be tritium in Will be remediation sampling addressed groundwater addressed showed no tritium in under ATI#

in 2006.

under ATI# the groundwater at this 435383 435383 location.

11 5/4/02 VB-3 Seepage WO 106767 Requested Sample Per IR, RP No 2002 05/20/02 replaced air leak - vent 0440231 repair.

showed was documents elease valve. Tritium above sampling. No found.

plume was identified background documents Will be round VB-3 in 2005.

particulate found. Will addressed Remediation being activity. Will be addressed under ATI# addressed under IR#

be addressed under ATI#

435383 435383.

under ATI#

435383 435383 8

RESPONSE

PIF/

Immediate Particulate Tritium 10 CFR Date Event Leak Size WR CRJIR Action Sample Sample 50.75(g)

Resolution 12 8/20/03 VB-4 1 gpm to WO 172376 None Sample No 2003 No 2003 9-9-03 replaced seat seat vault, no 99243232 analysis documents documents ring/float and top flooding detected no found.

found, gasket.

particulate Tritium Willbe radioactivity plume was addressed 8/27/03 173204 Stopped identified in under ATI#

Tritium plume was mod 2006. Will 43538310. identified around VB-testing.

be addressed 4 in 2006.

under ATI#

Remediation being 435383 addressed under IR#

435383.

13 9/11/03 VB-4 20-40 WO 175241 Secured No 2003 No 2003 No 2003 10/22/03 No work seat drops/min 99243232 booster documents documents documents performed. Leak pumps.

found.

found.

found.

determined to be from Will be Tritium Will be operating the system at addressed plume was addressed low flow. Tritium under ATI# identified in under ATI# plume was identified 435383 2006. Will 435383 around VB-4 in 2006.

be addressed Remediation being under ATI#

addressed under IR#

435383 435383.

14 11/18/04 VB-8 Popping /

WO 274328 Isolated No 2004 No 2004 No 2004 10/18/05 replaced

leaking, 0757898 Vacuum documents documents documents valve assembly. 2006 small leak breaker found.

found.

found.

remediation sampling within pit showed no tritium in the groundwater at this location.

15 5/19/05 VB-I 20 drop per WO 336401 Isolated No 2005 Yes.

Will be 12/18/05 replaced the minute leak )0744194 valve and documents Sampling addressed vacuum breaker from the air and WR requested

found, was under ATI#

assembly. Tritium release D0178930 repair.

performed.

435383 plume was identified valve.

Tritium around VB-I in 2006.

plume was Being addressed under identified in IR# 435383.

2006. Will be addressed under ATI#

435383 16 5/24/05 VB-6 Seepage WO 338111 Isolated No 2005 Per IR, Will be 10/19/05 rebuilt main seat from float/

00820879 leaking documents sampling addressed valve and replaced air seat area vacuum

found, was under ATI#

release valve. 2006 with one breaker.

performed.

435383 remediation sampling foot of water showed no tritium in in pit.

the groundwater at this l6cation.

9

RESPONSE

PIF/

Inunediate Particulate Tritium 10 CFR Date Event Leak Size WR CR/IR Action Sample Sample 50.75(g)

Resolution 17 1/16/06 VB-7 Bushing WO 442540 Reduce Sample No Will be Pending EACE in failure. Not 0883925 B/D. Take analysis detectable addressed progress. Tritium plume significant..

samples.

detected no tritium in under was identified around Evaluated particulate surface water ATI#

VB-7 in 2006, but was for radioactivity from this 435383 due to historical regulatory leak. Prior to leakage. Remediation complianc this leak, being addressed under e, isolated tritium above IR# 435383.

valve and background wrote WR

& below EPA drinking water limit identified in 2006 in wells used to characterize conditions near this vacuum breaker.

Responses varied from a request for normally scheduled repairs to an immediate remediation effort. The 2000 response effectively remediated the surface spill area, but did not effectively characterize the extent of condition to allow for full remediation due to weak management review and oversight of spill response activities (Root Cause 4).

A contributing cause common to many of the documented events is the lack of questioning attitude and oversight by Braidwood Senior Management to the radiological implications of blowdown spills. Issue ownership and follow through were lacking in all levels of management. Corrective actions 2 and 3 address training for all levels of management.

The tritium remediation plan will be tracked to completion under IR# 435383 and CAPR 2. The Braidwood Tritium Remediation Team has performed tritium characterization for the Circulating Water (CW) Blowdown (B/D) Vacuum Breakers (VBs) and performed integrity tests of the blowdown line. As of January 31, 2006, CW B/D piping acoustic testing determined that no leak above 1.0 gpm existed (minimum detectable level of testing equipment). The characterization of tritium levels in the vicinity of the vacuum breakers is described in Table 1. The station secured radioactive releases to the blowdown line on 11/23/05 and releases will remain secured until the tritium remediation team issues the final resolution under ATI# 435383-07.

10

b.

Event timeline with events that led up to this Root Cause Investigation October 1990 "DRAFT" Commonwealth Edison procedure, CSG-001, "General Action Plan for Response to Unmonitored Releases and Very Low Level Radioactive Spills" was developed in 1990 but not implemented. This procedure contained guidance for mitigating intrusion of low-level radioactive spills into the groundwater. The reason the procedure was not implemented could not be identified.

The failure to implement this procedure was not determined to be a root cause for three reasons. First, this procedure did not provide overall integrated guidance for spill evaluation and mitigation. Second, the reason the procedure was not implemented could not be identified. Third, no corrective action to prevent recurrence could be determined.

Therefore, the lack of integrated procedural guidance to ensure proper recognition, evaluation and timely mitigation of the radiological spill events was considered a root cause (Root Cause 3) for the ineffective response to Circulating Water (CW)

Blowdown (B/D) Vacuum Breaker (VB) leaks (Causal Factor 3, Root Cause 3).

1991 Illinois regulation 35 IAC 620 enacted, which places radioactivity limits on potable resource groundwater tritium concentration. This new regulation was not integrated into Company Procedures (Causal Factor 6).

November 26, 1996 Found 1" pipe from VB-1 to the air release valve failed. Estimated 250,000 gallons released to the ground.

In 1996, VB-1 had a leak of approximately 250,000 gallons due to an air release valve failure.

The only documented response to this event was a work order (96111970) to isolate and repair the valve. The work control process (currently Exelon procedure WC-AA-106) had no guidance for prioritizing radiological leaks which could enter the groundwater. (Failed Barrier 5). In the absence of any other recognized hazard, the current process prioritizes these work orders as a "C".

Corrective action 26 will revise WC-AA-106. No documentation could be found to indicate that any actions were taken to remediate the spill or address the potential radiological concerns. Since there was no Problem Identification Form (PIF) written to document the failure, there is no record of review of this event by Braidwood Senior Management. During this team's review of this event, the team could not find any documentation of sample analysis for radioactivity.

11

Station actions and interviews of site personnel documented that in the past, personnel did not respond to CW B/D leaks as an offsite radioactive release.

Rather, they focused on preventing. potential National Pollution Discharge Elimination System (NPDES) violations.

As long as the effluent (water) did not leave Exelon property, personnel did not always perceive a reason for concern, as NPDES requirements were considered met. The site personnel interviewed, that were present at the time of the 1996 event, were unaware of the Illinois regulation regarding groundwater tritium limits.

Engineering walkdown Preventative Maintenance (PM) procedure (currently Exelon Braidwood procedure ER-BR-400-101) and Operations Department (OPS) walk down PM procedure (currently Braidwood procedure OBwOS CBW-A1) did not contain any precautions or steps for addressing CW B/D spills that potentially contain tritium (Failed Barriers 12 & 13).

Operational procedures BwOP CW-12, BwOP WX-526TI and BwOP WX-501TI had no guidance to isolate the B/D system if a known leak had occurred during a routine radiological release to the Kankakee River (Failed Barriers 15, 16, & 17).

No documentation was located that implied a recognition of vacuum breaker leakage impact on the requirements of the ODCM, REMP (Radiological Effluent Monitoring Program), and 10CFR50.75(g). The 1996 Annual Effluent Report did not contain an evaluation of the vacuum breaker radioactivity released and did not contain the associated evaluation of the dose to the public (IR 455079) & (CA-15).

NOTE:

As of January 2006, Elevated levels of tritium have been identified in the groundwater on Braidwood Station property close to VB-I.

In one location on Braidwood property, the level of tritium was above the Illinois EPA ground water standards (20,000 picoCuries/liter).

At Braidwood Station there was no site or corporate procedure for guidance on low-level radioactive spills (Failed Barriers 4 & 6). The Hazmat procedures (BwAP 750-4 & BwAP 1100-16) did not address radiological spills (Failed Barriers 1 & 2).

December, 1998 Leak from VB-3. (See Attachment 12 for more details.)

November 20, 2000 Leak from VB-1.

12

November, 2000 Leak from VB-2. (See Attachment 12 for more details.)

December 2000

  • VB-2 Root Cause Report 38237 for equipment failures was completed.

December, 2004 Based on Operating Experience from the nuclear industry (OPEX),

Braidwood Station commenced increased investigation of environmental tritium.

January, 2005 Exelon chartered an investigation into tritium OPEX issues, with Braidwood Station providing a multi-disciplined team to support the efforts to better understand and mitigate environmental tritium issues.

March 17, 2005 On March 17th, the Illinois Environmental Protection Agency (IEPA) notified Exelon Nuclear Corporate Environmental that they were investigating tritium concentrations in wells near Braidwood Station in preparation for the Godley public hearing on Braidwood Station's NPDES permit renewal. [The Root Cause Team could not find evidence of entry of this item into the Corrective Actions Program (Missed Opportunity)].

" The IEPA was working with Exelon Nuclear Corporate Environmental to understand why one of the Braidwood Radiological Effluent Monitoring Program (REMP) wells along the Kankakee River was indicating about 400 pCi/L concentration of tritium. [Since initial REMP sampling was commenced, the Braidwood REMP reports documented two wells along the Kankakee River with elevated tritium (within limits). One well returned to background levels when the well was redrilled (new casing)]

" The IEPA was investigating why shallow groundwater well #2 in Godley was reported to have tritium. (Exelon Corporate Environmental log documents that Exelon, an independent contractor, and the IEPA analyses could not confirm any tritium above background levels in any of the Godley, IL wells.)

13

March 23, 2005 The Exelon Corporate Environmental log documents that Exelon, an independent contractor, and the IEPA analyses of samples from wells in Godley Illinois did not detect any tritium above background levels.

In preparation for the upcoming public meetings for the city of Godley, the IEPA requested (by phone) Exelon Corporate Environmental to have Braidwood Station sample for tritium at the following locations:

1. The cooling lake discharge canal
2. The northwest corner of the cooling lake
3. The two monitoring wells used for the previous environmental remediation sampling on the west side of the Turbine Building.

" The IEPA was informed that Exelon installed wells to determine a groundwater gradient near the blowdown line spill at VB-2 that occurred in November 2000. These wells were installed for hydrology analysis.

The IEPA requested that Exelon provide a sample of the offsite drainage ditch and samples from the four shallow monitoring wells that were installed in the area of the November, 2000 blowdown line leak.

  • The IEPA asked Braidwood Station to sample the shallow Godley well, which was reported to be contaminated with tritium, because the Agency would like to have a recent tritium analysis on it.

March 24, 2005 An Independent contractor sampled the following per IEPA March 23, 2005 request:

1. The cooling lake in the discharge canal
2. The cooling lake in the northwest corner
3. The two monitoring wells used for the previous environmental remediation sampling (two wells closest to the Turbine Building)

Additional Exelon samples:

4. The cooling lake on the east-west dike approximately halfway in the middle
5. The offsite drainage ditch
6. The four shallow monitoring wells that were installed in the area of the November 2000 blowdown line leak 14

April 1, 2005 Results (reference Braidwood Chemistry Department Sample Log) from the March 24 tritium samples taken at Braidwood Station indicated presence of tritium above background in the following locations (See for Map):

1. The cooling lake in the discharge canal - < background
2. The cooling lake in the northwest corner - < background
3. Sample point MW-4, near the November 2000 VB-2 leak -. above background Sample point MW-6, West side of Turbine Building -

above background Additional Exelon samples

4. The cooling lake on the east-west dike approximately halfway in the middle - < background
5. Sample point BD-101, Braidwood drainage ditch above background
6. The four shallow monitoring wells that were installed in the area of the November 2000 blowdown line leak. Three were < background.

One was above background The levels identified in these samples were well below the federal standard of 20,000 picoCuries/liter (pCi/L).

  • Although the tritium levels were well below federal standards, Braidwood commenced detailed sampling and investigation.

April 15, 2005 Exelon sent Godley well results and the second sample on the drainage ditch to the IEPA. Samples had been collected on April 7, 2005:

Sample Location Sample ID Result BD-101 (Drainage Ditch)

BDSW-1 665 twice background Godley Rec. Center BDWW-1666 less than background Godley Rec. Center BDWW-1 667 less than background April 25, 2005 IR 328451 was generated to identify tritium levels above background in the Braidwood drainage ditch.

15

May 5, 2005

  • Additional samples were taken at three locations in and around the Braidwood drainage ditch in an attempt to better define the source of the tritium.

May 9, 2005 Due to the results of the March 24, 2005 sample and confirmatory sampling of Braidwood drainage ditch, Braidwood Station expanded the sampling and investigation to focus on both surface water and groundwater sample points.

May 10, 2005 Five shallow groundwater wells (GW-1, GW-2, TW-20, OW-32 and OW-

33) were sampled (See Attachment 7 for Map).

These five wells are located onsite and are positioned between the Braidwood drainage ditch and the Village of Godley. These samples were to provide more detailed information to samples previously collected on May 5.

No tritium was detected above background concentrations in any of these five samples.

May 17, 2005

" A conference call was held with IEPA to exchange recent sample results and to discuss sampling in the Braidwood Station onsite wells (GW-1, GW-2, TW-20, OW-32 and OW-33) (See Attachment 7 for Map).

The IEPA reported all tritium samples as less than background, which corroborated the site's results.

" The IEPA stated that they would acquire four samples from residents in Godley who live along side the drainage ditch and would analyze the samples for tritium.

The Agency would provide duplicate samples for Exelon tritium analyses and would notify us when the sampling was scheduled.

May 18, 2005 A 20 drop per minute leak from the pilot valve of vacuum breaker #1 (VB-

1) was identified during a walk down by Braidwood Engineering.

A sample was acquired and sent for analysis. (See Attachment 7 for Map) 16

May 19, 2005 The tritium concentration in the sample of the leak catch tray at the VB-1 leak was above the IEPA standard for groundwater. (There was no evidence of leakage outside of the catch tray).

May 23, 2005

" Braidwood Station briefed the Nuclear Regulatory Commission (NRC)

Inspector from the Region III Office on the drainage ditch tritium results.

An overview of the sampling performed to date, along with the results of the sampling and a copy of the collated sample results, were presented to the NRC as part of the routine Offsite Dose Calculation Manual (ODCM)/Radiological Environmental Monitoring Program (REMP) inspection.

  • Tritium analyses performed on five water samples collected at Braidwood Station on May 20, 2005 were less than background except for the VB-3 Pit tritium concentration which was above background (See Attachment 12 for VB-3 timeline).

June 14, 2005 Exelon and IEPA acquired four samples from the Godley wells per the May 17 request.

June 20, 2005

  • As part of the investigation to determine the source of tritium, the station received the independent contractor proposal to install monitoring wells to focus on:

o Examining the groundwater impact in the area of VB-1 located south of the switchyard o

Determining the movement and direction of groundwater and its relationship to surface water on both the east and north side of the Braidwood Station property June 28, 2005

  • The results of the four Godley well samples taken on June 14, showed no tritium levels above background.

17

July 22, 2005 Exelon installed monitoring wells to investigate potential leakage around VB-1 and VB-3 that may be contributing to leakage in the Braidwood drainage ditch: (See Attachment 7 for Map) o Sample point MW-1 06, near the fresh water holding-pond o Sample point MW-1 07, SE corner of the switchyard near VB-1 o Sample point MW-108, east of VB-1 near the CW B/D line o Sample point MW-1 09, east of the switchyard near the Braidwood ditch September 23, 2005 Exelon pursued additional resources to expand the scope of the tritium investigative activities to more clearly define the source of the tritium, which had been discovered in the drainage ditch. This information was communicated by phone to the IEPA.

October 2005 Exelon installed monitoring wells as part of an expanded scope of the tritium investigation: (See Attachment 7 for Map) o Sample point MW-110, north of the meteorological tower o Sample points MW-111, MW-112, and MW-113, north property line near Smiley Road October 25, 2005 Initiated IR# 390133 to address difference between historical annual liquid discharge curie content and the UFSAR description. Investigation of this difference determined that no change was required.

November 9, 2005 Two of the four groundwater samples collected on October 19 and October 20, 2005 from the new monitoring wells exceeded the Offsite Dose Calculation Manual (ODCM) Lower Limit of Detection of 2000 pCi/L.

Upon this indication, Braidwood Station assembled an Exelon Issues Management Team (OP-AA-1 06-101-1002) to evaluate the tritium issue.

18

November 22, 2005 Nuclear Oversight (NOS) completed the ODCM, REMP, Effluent and Environmental Monitoring Audit Report, NOSA-BRW-05-08 (AR# 287718).

NOS found no issues of note. NOS did not identify that the ODCM did not include Illinois State Groundwater Regulations (Failed Barriers 28 & 29).

November 23, 2005

  • Braidwood Station terminated the use of the Circulating Water (CW)

Blowdown (B/D) system for radioactive liquid releases pending resolution of this root cause investigation and appropriate corrective actions.

November 30, 2005 Issues Management Team was formed to address tritium issues.

December 2, 2005 Emergency Notification System (ENS) notification made to the NRC due to the notification of other -government agencies' (IEPA) and a press release.

January 15, 2006 As this RCR was being finalized, a leak occurred on VB-7 due to failure of an internal guide and was documented on IR# 00442540. (See analysis section of how this issue is addressed) (See Attachment 7 for Map)

  • The standing water posed no radiological concern because CW B/D radiological releases had been held in abeyance since November 23, 2005.

The standing water in the vicinity of VB-7 was sampled for gamma radioactivity and tritium (no radioactivity detected) and evaluated for NPDES compliance. An environmental specialist verified that the leakage did not reach runoff ditches or creeks and therefore NPDES requirements were met.

Prior to this leak, tritium above background and below the EPA drinking water limit was identified in 2006 in wells used to characterize conditions near this vacuum breaker. The source of this tritium is likely to be leakage prior to 1996 as no record of leakage subsequent to 1996 could be located.

19

Analysis:

The Root Cause Investigation Team interviewed personnel and reviewed the response procedures, regulations, historical documentation, and environmental impacts. An Event and Causal Factor (E&CF) Chart (Attachment 4) was utilized for Cause and Effect Analysis (Attachment 3), Change Analysis (Attachment 5) and Barrier Analysis (Attachment 2).

Unplanned Tritium releases from Braidwood Station:

The 2000 event Root Cause Report (RCR) 38237 CAPR's addressing the vacuum breaker failures were reviewed and have been determined effective in preventing major vacuum breaker failures since 2000 through the end of 2005. The purpose of the Root Cause in 2000 was to determine the cause of those failures. RCR 38237 CAPR implemented a revised preventive maintenance program for the float operated vacuum breaker valve assemblies for the CW B/D and Makeup Systems.

This Preventative Maintenance (PM) was developed to include specific intervals for inspection of valve internals and provided for periodic replacement of the valves (refer to Attachment 6 for CW B/D description). This team concludes that the RCR 38237 CAPRs have effectively prevented recurrence of the large volume leaks (as described in Table 1) caused by corroding valves that did not receive effective PMs and water hammer damage due to design configuration. Currently, daily walkdowns of the blowdown vacuum breakers are being performed to verify that no leakage is occurring.

On January 16, 2006, a leak occurred on VB-7 due to failure of an internal guide bushing and was documented on IR 00442540. EACE 442540 is performing an evaluation of this failure. The results of the EACE will be reviewed to determine if the findings in this root cause are still valid. Corrective Action 29 will track this issue. The standing water posed no radiological concern because radiological releases through the CW B/D line had been terminated pending completion of this root cause report and completion of associated corrective actions.

Root Cause Report (RCR) 38237 Corrective Action to Prevent Recurrence (CAPR) revised the system walkdown inspection requirements, including specified frequency of walkdowns and documentation and reporting of walkdown results. RCR 38237 CAPR also replaced the vacuum breaker assembly with a surge-protected configuration.

Engineering has performed an effectiveness review of these actions (ATI 38237-10) and in the three years since the initial effectiveness review, there had been no major equipment failures, which leads to the conclusion -that the actions taken from the root cause report are effective in eliminating the possibility of large volume leakage due to major vacuum breaker failure.

20

Effectiveness of Braidwood Station response to radioactive leaks:

Interviews played an integral part in the determination of this root cause due to the lack of written information that was available from the Corrective Action Program (CAP) to this Root Cause Investigation Team for the Circulating Water (CW)

Blowdown (B/D) events.

The fact that some spills were not captured in the Corrective Action Program is indicative of weak management review and oversight of spill response activities (Root Cause 4).

A potential root cause that was considered was that draft Commonwealth Edison procedure CSG-001, "General Action Plan For Response To Unmonitored Releases And Very Low Level Radioactivity Spills" was not implemented.

This procedure contained guidance for mitigating intrusion of low-level radioactive spills into the groundwater.

There was no reason found as to why the procedure was not implemented.

The failure to implement this procedure was not determined to be a root cause for three reasons. First, this procedure did not provide overall integrated guidance for spill evaluation and mitigation. Second, the reason the procedure was not implemented could not be identified.

Third, no corrective action to prevent recurrence could be determined.

Therefore, the lack of integrated procedural guidance to ensure proper recognition, evaluation and timely mitigation of the radiological spill events was considered a root cause (Root Cause 3) for the ineffective response to Circulating Water (CW) Blowdown (B/D) Vacuum Breaker (VB) leaks (Causal Factor 3, Root Cause 3).

For example, in a number of events the station addressed the NPDES concerns but no Radiation Protection (RP) individuals were engaged to address radiological concerns.

Additionally, when personnel with the requisite knowledge base were involved, the lack of a pre-engineered solution that could be executed was not available. This hampered response, as each step had to be created and reviewed before actions occurred.

At the time of the 2000 spill, the final remediation steps were missed under these circumstances, as independent expert reviews/challenges did not occur.

21

Evaluation Methods used during the investigation process for the Root Cause.

RC Tool Why used Advantages Disadvantages overcome Event and Causal Utilized due to the complexity Provide an illustration of the While time consuming, enlisted Factor Chart (Att 4) of the issues and actions over whole problem and a full-time Root Cause person time.

contributing factors, for the skill/experience and time to create an E&CF Chart.

Works very well with barrier The large number of events analysis, which became verge n a

ever, necessary during the verged on a CCA. However, evaluation, one event was taken to represent them all and the analyses were completed utilizing that event (the 1998 event) as the template.

TapRoot Used to assign the cause codes Consistent approach for more Difficult to utilize and for individual causes of the reliable cause coding.

understand categories.

event.

Technique was used in conjunction with Trending/Coding procedure and Team input/brainstorming of causes.

Barrier Analysis (Att 2)

Used extensively, as people, Used to identify causal factors Utilized Team brainstorming to physical, and administrative systematically, With the E&CF assure all barriers were barriers should have prevented chart and Cause & Effect recognized.

the issue.

analysis to identify process weaknesses. Supports proposed corrective actions.

Change Analysis Team tried to utilize to evaluate Made for a good starting point Information contained in this (Att 5) changes in procedures and in analysis of the E&CF chart, attachment was inadequate to regulations.

use effectively and was therefore not utilized as an input to this root cause report.

Cause and Effect Found the "Why" Stair Case This analysis method was key Utilized E&CF chart and area Analysis (Att 3) instrumental due to the large in finding the common/root experts in OPS, RP, Chemistry number of failed barriers, cause used with barrier

- Environmental, and other analysis.

stations as well as RA and Corporate to ensure entire background was understood for this complex problem.

Failure Modes and Not Used Not Used Not Used Effects Analysis 22

Evaluation:

Cause (describe the cause and Po m identify whether it Problemis a root cause or a Statement contributing cause)

Basis for Cause Determination Unplanned releases to the ground from unauthorized release paths.

Causal Factor 1, Root Cause 1 The root cause of the large volume leaks in 1998 and 2000 is documented in Root Cause Report (RCR) 38237, which determined that the Circulating Water (CW)

Blowdown (B/D) Vacuum Breaker (VB)

Valves had inadequate preventative maintenance programs and inadequate design configuration.

Preventive Maintenance -The preventive maintenance program in year 2000 had no requirement to perform any kind of internal valve inspection or operational check and no requirement to periodically replace the valves. The vacuum breaker valves were essentially installed as runto failure components.

There were no Technical Specification requirements or NRC commitments to conduct periodic maintenance. Prior to 1999, walkdowns of the blowdown system were performed annually.

In July l 999, a preventive maintenance template from STANDARD NES-G-08, CoinEd Performance Centered Maintenance (PCM) Templates, was adopted for application~to the vacuum breaker valves. The particular template chosen is specifically applicable to spring actuated safety relief valves, and contains no discussion of applicability to float type valves. The predefine task description is "perform setpoint verification and seat leak check, or replace valve". The periodicity was set at 10 years. The template chosen was the closest match from all those available in the standard PCM template index.

.Design/Application -The barrier was challenged when system operation was changed without changing the design or configuration of the vacuum breaker assemblies.

Original CW blowdown system operation provided for controlling blowdown flow using valves at the river screen house, thus the system would always remain full of water. This method of operation was abandoned within the first two years of operation due to repetitive failures of the control valves. Operation thereafter provided for controlling blowdown flow using valves located in the plant near the main condensers and when flow is secured, the blowdown line would depressurize and partially drain resulting in a potential pressure surge when flow was reinitiated. Discussion with the valve manufacturer revealed that if the valves are subjected to significant pressure surges, they should be equipped with surge protection. The current configuration had no surge protection. The reason why the system operation was changed rather than correcting the material condition of the valves at the river screen house was not pursued since that decision was historical. Similarly, the reason the change was made without considering impact on the vacuum breaker design/configuration cannot be determined.

On January 16, 2006, a leak occurred on VB-7 due to failure of an internal guide bushing and was documented on IR 00442540. EACE 442540 is performing an evaluation of this failure. The results of the EACE will be reviewed to determine if the findings in this root cause are still valid. Corrective Action 29 will track this issue.

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Cause (describe the cause and Problem identify whether it is a root cause or a Statement contributing cause)

Basis for Cause Determination Causal Factor 2, Although the corrective actions from the 38237 Root Cause Report were Root Cause 2 effective, the report did not address "small" spills because the need for a near The root cause zero leakage standard was not k"own or suspected. The near zero leakage of the small requirement was not identified in the 2000 Root Cause Report investigation due leaks, which to a lack of technical rigor/questioning attitude. For details, refer to Attachment both preceded 12.

and succeeded the 1998 and 2000 leaks, was that the need for a near zero leakage standard was not identified, due to a lack of Technical Rigor/Questionin g Attitude.

Inadequate Causal Factor 3, After this root cause was identified, it was analyzed to determine if it was response to Root Cause 3:

appropriate for this event. In other words, the team considered whether the unplanned The first root "why" question had been asked enough to adequately resolve the problem. The releases.

cause for the team attempted to ask "why" and there is no clear/concrete documentation to ineffective explain why this 1990 procedure was not implemented (Failed Barrier, FB-4).

response was a Utilizing TapRoot analysis process, the root cause is the most basic cause (or lack of causes) that can be reasonably identified that management has control to correct integrated and when corrected, will prevent (or significantly reduce the likelihood of) the procedural issue recurring. In this event, Braidwood Senior Management has the ability to guidance to implement integrated procedural guidance to ensure thenecessary knowledge of ensure proper local hydrology, the impact of low-level tritium leaks, and groundwater recognition, regulations is directed to ensure consistent mitigation and remediation of future evaluation, and events. Thus, it was concluded that the root cause statement met the criteria of timely mitigation the TapRoot definition and it was appropriate for this event.

of the (Failed Barriers FB 1 -17)

(See Attachment 2) CSG-001 1990 (draft only) radiological spill contained guidance regarding underground transport mechanism for tritium and events.

directions to remediate this pathway.

Procedures for responding to and assessing radiological spills are either non-existent or inadequate. There was limited guidance to acknowledge 35 IAC 620 requirements or subsurface transport mechanisms to provide dose to the public. Failed barriers 1-17 address lack of integrated procedural guidance to ensure proper evaluation of the event, including knowledge of local hydrology, the impact of low-level tritium leaks, and groundwater regulations. This procedure contained instructions for mitigating intrusion of low-level radioactive spills into the groundwater. The reason the procedure was not implemented, could not be identified. Because this procedure did not provide overall integrated guidance for spill evaluation and mitigation, the failure to implement the procedure was not considered a root cause.

Therefore, the lack of integrated procedural guidance to ensure proper recognition, evaluation and timely mitigation of the radiological spill events was considered a root cause (Root Cause 3) for the ineffective response to Circulating Water (CW) Blowdown (B/D) Vacuum Breaker (VB) leaks (Causal Factor 3, Root Cause 3).

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Cause (describe the cause and Problem identify whether it is a root cause or a Statement contributing cause)

Basis for Cause Determination Inadequate response to unplanned releases.

Causal Factor 4, Root Cause 4.

A second root cause for the ineffective response was weak management review and oversight of spill response activities.

In review of the 2000 Issues Management Team notes and other available documentation, the ineffective response from both the station and corporate levels appears to have been due to a lack of clear delineation of specific responsibilities during radiological spill response and remediation efforts.

Specifically, the interface of site and corporate Radiation Protection, Chemistry and Environmental departments are not clearly defined.

Due to the cross discipline teams needed to respond /document a low level radioactive leak and the lack of one procedure to integrate the response, CAPR 4 will ensure all aspects are covered.

Original 2000 root cause (38237) was too narrowly focused.

The Issues Management Team actions had no accountability or tracking through the CAP process.

Did not properly execute issue management procedures.

Unaware of the 1991 State regulation regarding tritium limits.

A Senior Corporate Manager was chosen to assemble and direct the radiological remediation team. Four Corporate procedures which direct issues management were properly entered to identify, evaluate, remediate and communicate the radiological concerns. The four procedures include:

NSP-RP-6101, "10 CFR 50.75(g)(1) Documentation Requirements" CWPI-NSP-I-I, "CAP Process Manual of Common Work Practice Instructions

- Instruction on Event Response Guidelines" OP-AA-101-501, "NGG Significant Event Reporting" OP-AA-101-503, "NGG Issues Management".

However, no historical documentation could be located. to demonstrate that the procedures (other than NSP-RP-6101) were fully executed. This indicates weak execution of the spill remediation plan by the Issues Management Team and weak Braidwood Senior Management review and oversight of spill response activities. (Root

-Cause 4)

The water was pumped back into the B/D line on 11/10/00 and hydrology wells were installed in the area of the 2000 leak to characterize the local hydrology. Based on calculations and conclusions by a professional hydrologist, underground water in the area of VB-2 would take approximately 15 years to flow offsite. IDNS and EPA were informed. Further remediation efforts were not developed after the surface water was removed. Further efforts were limited to the mechanical failure oriented Root Cause Report (RCR) 38237 and the 10 CFR 50.75(g) characterization study. The 10 CFR 50.75(g) study did not sample groundwater for tritium, even though the NSP-RP-6101 procedure and the regulation clearly state to identify all radioisotopes (Failed Barrier 3). This procedure will be strengthened per CA 21. As a result, the groundwater tritium went undetected until the 2005 tritium sampling discovered the groundwater tritium.

This indicates weak Braidwood Senior Management review and oversight of spill response activities. (Root Cause 4)

See timeline for 2000 event, for further substantiation of needed improvements in Braidwood Senior Management oversight.

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Cause (describe the cause and Problem identify whether it is a root cause or a Statement contributing cause)

Basis for Cause Determination Inadequate Causal Factor 5, Personnel were not aware of state regulations (35 IAC 620) to revise procedures and response to contributing training for these action levels. Additionally, those who would audit the ODCM/REMP unplanned cause. Personnel programs were also not aware that the regulatory and procedural deficiencies existed.

releases.

were not aware (See Attachment 10) If the site had been aware of the requirement, then the site would of state likely have been driven to properly evaluate groundwater.

regulations (example: 35 IAC 620)

Causal Factor 6, (FB-30) Interviews with individuals indicated that notice to other Site Departments when Notification:

an event occurred did not always occur. This was also observed through a review of the Processes and corrective actions database, which indicated that valve leakage was not always identified procedures for in CAP. In the current corrective action process at Exelon, all issues whether communication organizational or equipment related are entered and tracked in the corrective action not well defined, program.

(FB-31) Interviews with individuals indicated that a process for formal notification to the sites of State regulation changes is lacking. This was also observed through a review of applicable regulations and the lack of those regulations being consistently addressed in the ODCM, Reportability Manual, and other applicable procedures.

Causal Factor 7, Training does not exist for Operations, Chemistry or RP personnel for specific Training:

responsibilities related to radiological spill response and assessment (reference General training )

has no prompt to have personnel report environmental spills for assessment of radiological conditions.

Extent of Condition:

All Exelon Nuclear facilities are potentially affected, with added emphasis on Pressurized Water Reactors due to tritium production rates. A Nuclear Event Report (NER 428868-12) will require all Exelon Sites to take actions to research historical spills and determine if tritium remediation is required. The Nuclear Industry will be informed of the issue through a Nuclear Network Operating Experience Report (NNOE 428868-13).

Other spill type (Hazardous Material) response procedures were reviewed and determined to have effective guidance through the Hazmat and Environmental programs (Attachments 2 & 8). These programs and procedures will receive further review and update to integrate radiological interfaces (CAPR 3).

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Cause being addressed Extent of Condition Review CF-I, RC-1, This condition applies to any site using a similar configuration for blowdown and radioactive release CAPR-1: Significant path. ATI 428868-13 was created to update the Nuclear Notification Operating Experience (NNOE) vacuum breaker leaks to communicate this issue to the Nuclear Industry. ATI 428868-12 was created to update the (NER) in 1998 and 2000.

to communicate this issue to all Exelon sites. Issue Reports 00453379 and 00453387 document that Byron and LaSalle Stations have similar CW B/D and make up design configurations.

CF-2, RC-2, This issue applies to all Exelon Nuclear Stations. All sites produce tritium. Pressurized Water CAPR-2: Continuing Reactors produce a higher amount of tritium due to the usage of boron. ATI 428868-13 was created small vacuum breaker to update the Nuclear Notification Operating Experience (NNOE) to communicate this issue to the leaks after the 2000 Nuclear Industry. ATI 428868-12 was created to update the Nuclear Event Report (NER) to event.

communicate this issue to all Exelon sites. Issue Reports 00453379 and 00453387 document that Byron and LaSalle Stations have similar CW B/D and make up design configurations.

CF-3, RC-3, This issue applies to all Exelon Nuclear Stations. All sites produce tritium that can possibly migrate CAPR-4 Procedures -

into groundwater. Pressurized Water Reactors produce a higher amount of tritium due to the usage of A lack of integrated boron. ATI 428868-13 to update the Nuclear Notification Operating Experience (NNOE) to procedural guidance to communicate this issue to the Nuclear Industry. ATI 428868-12 was created to update the Nuclear ensure proper Event Report (NER) to communicate this issue to all Exelon sites.

recognition, evaluation, and timely mitigation of the spill events.

CF-4, RC-4, This issue applies to all Exelon Nuclear Stations since the review and oversight is controlled by CAPR-3 & 5:

corporate procedures. Other spill type (Hazardous Material) response procedures were reviewed and Weak management determined to have effective guidance for non radiological programs (Attachment 8). These review and oversight programs and procedures will receive further review and update to integrate radiological interfaces.

of spill response CAPR 3 (Human Performance) and CAPR 5 (Issues Management) address these issues for all sites.

activities.

CF-5, Regulations:

All sites have the potential for unplanned releases. The event at Braidwood station is one example.

Personnel were not There are numerous other nuclear industry events (OPEX) that resulted in groundwater aware of State contamination. For this reason, each site must assess the vulnerability of piping leaks and Regulations contaminating groundwater. This assessment is not limited to those plants that make liquid discharges. The concern is leakage into groundwater - not dose from liquid effluents to a defined outfall release point. Which is to say, that the ODCM does not direct routine measurements for leakage locations that may produce an exposure pathway. Issue Reports 00453379 and 00453387 document that Byron and LaSalle Stations have similar CW B/D and make up design configurations.

Corrective Actions 5 through 14 will address this vulnerability at each site.

CF-6, Notification:

This issue applies to all Exelon stations. CAPR 4, CAPR 5, and CA-14 will address this Processes and vulnerability at each site.

procedures for communication not well defined.

CF-7, Training:

This issue applies to all Exelon Nuclear Stations. ATI 428868-12 to update the Nuclear Event Report Personnel not all (NER) to communicate this issue to all Exelon sites.

aware of concern with CW B/D piping and secondary side effluents being tritiated water.

CW B/D vacuum Other Exelon/Amergen Nuclear sites were contacted to determine how those plants are configured breaker design for circulating water blowdown and makeup and if they have experienced any similar problems with vacuum breaker float assembly failures. Byron and LaSalle stations were the only stations confirmed to have circulating water blowdown and makeup systems that utilize vacuum breakers in their design.

For circulating water blowdown and makeup systems, the extent of condition is limited to Byron and LaSalle. Reference Byron IR 453379 and LaSalle IR 453387 for the respective site OPEX review.

27

Risk Assessment:

Plant-specific nuclear Basis for Determination safety risk consequence None There are no plant specific risks associated with this issue. There are no risks to the CW Blowdown system as a result of this issue, since the leaking (failed) vacuum breaker assembly would still function o prevent a vacuum from forming and causing damage to the CW Blowdown piping. This issue has no impact for core damage/accident mitigation. The event was reportable under Reportability Manual, SAF 1.9, News Release or Notification of Other Government Agencies.

Previous Events:

The only previous event in terms of Braidwood's response to a release of a contaminant to the nearby environment would be PIF A2000-02683, Oil in North Runoff, where waste oil from an oil separator overflow entered a ditch which formed the boundary between Braidwood Station and Godley on the Station's west side. However investigation of this event by Braidwood Station and Illinois EPA did not identify any contamination of surface or groundwater in Godley. This event is listed in the table below as part of the discussion of events found in the search of the INPO web site.

Braidwood has identified 17 leaks from the Circulating Water Blowdown piping, and three of the events, 1996, 1998, and 2000, resulted in flooding of local areas. The previous events table contains a summary of leaks identified from records in the Corrective Action Program and the Work Control Process, including the Station's response.

The majority of the blowdown leaks were small (as described in Table 1) and the water does not appear to have overflowed out of the vacuum breaker vault. However, to verify this, wells were drilled in the area of each of the Vacuum Breakers and tritium samples analyzed. The areas around VB-1, VB-2, VB-3, VB-4 and VB-7 have been verified to contain tritium. The entire length of the CW blowdown line has been tested for integrity and found to be intact, with no leaks above the minimum detection limit of 1.0 gpm.

The INPO website was searched for Operating Experience (OPEX) using the terms tritium, release, offsite, and groundwater. Passport was also searched using similar parameters.

There have been numerous events concerning unplanned releases to the environment at numerous sites.

For the most part, the descriptions of the, events do not discuss remediation or continuing monitoring, but rather a statement that no activity was released from the site or detected offsite.

One instance (Pickering, 1997) was found where the licensee attempted to remediate the tritium in the groundwater by flushing the ground with fire protection water. This did not reduce the tritium concentration in the groundwater. Only one event (Waterford, 2003) reported detectable increases in offsite tritium due to a primary to secondary tube leak.

The 2000 overflow of a Braidwood oil separator was included because of its relevance in terms of potential impact to the public and station response.

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Operating Experience (OPEX) reports were reviewed. The OPEX reviewed did not reveal any missed opportunities to have prevented the events in this root cause report.

Braidwood Station had no known active leaks and had no increases in any routine radiological environmental samples when low level groundwater radioactivity due to tritium was discovered.

The following are summaries of relevant OPEX events in chronological order:

Previous Events Previous Event Review INPO Oyster Creek, 1-20-81 Condensate storage and radwaste transfer piping leaks resulted in underground release of radioactive liquid. No remediation was performed.

SER 4-81 Hatch, 12-3-86, OE1905, 124,500 gal from a spent fuel pool leak went into the storm drain system and eventually Operating Plant reached a swamp area within the owner-controlled property. The water discharge resulted Experience from a loss of air to the inflatable seals used in the transfer canal between the Units 1 and 2 Spent Fuel Pools. The area was decontaminated, and no activity was detected outside Georgia Power property.

Prairie Island, 5-1-92, Elevated levels of tritium (concentrations of 1, 300 to 1,500 pCi/L) were detected in an PNO3-92-023, Elevated onsite groundwater well. Offsite wells sampled showed no increase in-levels of tritium.

levels of tritium detected No further details or follow up actions have been issued on this Preliminary Notification in onsite well of Occurrence.

Dresden, 10-19-94, Degraded cathodic protection system and breached wrapping of underground piping OE7067, Cathodic results in through-floor pitting in both contaminated condensate storage tanks and three Protection System radwaste tanks between 1992 and 1994, through-wall pitting on the HPCI test return line Degeneration and a demineralized water line, and underground fire protection piping degraded in several areas. The leakage was characterized and a remediation plan to monitor the tritium plume was implemented. No documented review of OE 7067 could be found for Braidwood Station.

Pickering A, 7-18-97, Since 1979, groundwater at the upgrader plant Pickering A (UPP-A) has had tritium levels SER PD97184, Elevated in the surrounding groundwater that are above background. Several attempts have been Concentrations of Tritium made to reduce the tritium concentrations in the groundwater including pumping in Groundwater groundwater with low levels of tritium to the lake and flushing the area with fire protection water. Tritium concentrations in groundwater, however, remained constant.

Increased tritium is due to spills and unplanned releases and not taking appropriate action to remediate the area after spills or discharges.

Braidwood, 6-25-00, PIF Oil separator #1 overflowed into the north runoff and offsite. Root Causes were A2000-02683, Oil in inadequate preventative maintenance of the north runoff ditch and the oil separator.

North Runoff Remediation and offsite sampling was performed to mitigate and assess the impact to the public.

Limerick, 2-18-02, Event Tritium concentrations of 10000 pCi/L were detected in the normal waste holding pond.

Number 352-020215-1, There was no plant impact, no personnel exposure, and no release above regulatory limits Tritium Identified in to the environment. Groundwater monitoring is not performed.

Normal Waste Water Holding Pond and Auxiliary Boilers 29

I Previous Events Previous Event Review Prevous vens Prviou Evnt Rvie Salem, 9-18-02, OE15788, Spent Fuel Pool Leakage, and OE15859 Tritium Detected in Groundwater Samples from Onsite Monitoring Wells (Follow-up to OE15788)

Leakage from the Unit 1 Spent Fuel Pool as a result of clogged telltale drains was found.

To determine the affect of the leakage on site groundwater, 8 monitoring wells were installed as reported on 3-19-03. Tritium results were as high as 69,200 pCi/L in one sample, and positive results were found in 4 other wells. As reported on 7-25-03, sample results obtained from new wells indicate tritium concentrations of 3.5M pCi/L and 125K pCi/L. Gamma scans of samples from both locations detected no other radionuclides.

There is no indication of any offsite release and there is no threat to the public or company employees. On 5-3-04, NRC Information Notice 2004-05: Spent Fuel Pool Leakage To Onsite Groundwater is issued describing the Salem event. Braidwood Station does not have any reasonable release paths from our spent fuel pool to the groundwater. The NER issued by Braidwood requires evaluation of all potential tritium spill paths.

Waterford, 2-28-03, Primary to secondary leakage from steam generator tube/tube plug degradation resulted in OE15894, Substantial an increase in secondary tritium levels and approached a reporting limit listed in the Rising Trend in Tritium Technical Requirements Manual (TRM) for a local drainage canal.

Activity Measured at (REMP) Sample Location at Waterford Dresden, 7-31-04, HPCI suction line had been leaking since Nov 2003. Up to 6M pCi/L was detected in CR248494, High Tritium monitoring wells and stormdrains on site. Hydrology study shows the event does not Activity In Onsite Wells affect residential wells near the site. Routine monitoring established for 1994 event had and Storm Drains been discontinued. Remediation consists of quarterly monitoring of plume as it dissipates, verifying it does not migrate off site.

Braidwood, 12-8-04, Site approaches ODCM quarterly dose limits of 7.5 mrem/unit following the AlR1 I OE19305 / OE19623, refueling outage due to failed fuel conditions. The cause of challenging the offsite dose Station Challenges limit is that the effluent release procedures and processes did not have limits or controls in Effluent Quarterly Dose place to account for failed fuel conditions.

Limits During Unit 1 Outage Watts Bar, 2-8-05, 550,000 pCi/L discovered during routine onsite environmental monitoring. No tritium has OE20318, Onsite been detected in water samples from offsite monitoring locations, public drinking Groundwater Tritium supplies, or the Tennessee River. Source is from a Cooling Tower Blowdown Line or Above Reporting Limits previous leakage from a temporary effluent line.

Indian Point, 9-1-05, Hairline cracks in the liner of the Unit 2 spent fuel pool are found. On 10-5-05 (Event OE21506 Spent Fuel Pool Report 42014), 21100 pCi/L of tritium was detected in monitoring well MW-111 located Hairline Crack in the Indian Point 2 transformer yard. Other wells showed negative. The sampling that was done was part of an ongoing investigation to verify and quantify previously identified leakage, potentially from the spent fuel pool. Continued sampling discovered tritium in 6 of 9 onsite wells.

Haddam Neck, 10-31-05, Spent Fuel Pool leakage to the site groundwater was discovered when removing soil east Event 42099 of the Spent Fuel Building. The quantity of water leaked is unknown. Estimates based on historic Spent Fuel Pool evaporation data indicate that the leak was small - on the order of a few gallons per day. Based on readings from down-gradient monitoring wells, there is no travel offsite.

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Previous Events Previous Event Review EVENTS IDENTIFIED Description and review of event.

AT BRAIDWOOD STATION 12-5 A1998-04324, AR written Monday after Southern Div. PR contacted by neighbor. They sighted leaking CW Blowdown Vacuum vacuum breaker from the south was unaware of the "pond" to the north: Chemistry Breaker Leak - pond of contacted environmental services. AR status changed to B I due to possibly exceeding water found on property, release permit limits. This incident was initiated when (name removed) was contacted with standing water in about the pooled water by a local resident. (Name removed) and (name removed) road ditch along Smiley investigated and noted the pool was located on station property. There was minor Rd.

puddling in the adjacent ditch but this water did not run off. Environmental services were consulted and since the ponded area was restricted to station property there was no NPDES concern. The blowdown system was shut down to isolate the vacuum breaker and stop the leakage. WR 980127749 was written to repair the vacuum breaker. The work was performed over the weekend of 12/5. The station response to this event was excellent. Maintenance had this repaired in -24 hrs. This failure had prevented the station from performing liquid releases.

11-7 A2000-04281, The valve had been in this condition for an unknown period of time, most likely several Failed Circulating Water days. The ground in the nearby area is sandy and drains quickly. The ground was Blowdown Vacuum saturated with water. Upon the discovery of the leak operations isolated CW blowdown Breaker Caused on the afternoon of 11/6/2000. Draining of the piping to affect the repairs was started on Unplanned Flooding the morning of 11/7/2000. The 0CW135 (manual isolation to 0CW136) and the 0CW136 Outside the Power Block -

CW blowdown vacuum breaker valve were replaced with new valves by 1600 hrs 0CW136 CW blowdown 1 1/7/2000. Once a year a visual inspection of the blowdown and make up lines is valve was found leaking performed, including the vacuum breakers. The float in question is an internal part and past its main seat.

cannot be inspected without disassembly of the valve. A degraded condition could be found by noting some leakage past the valve seats. This is the first failure of this type. A schedule of replacements will be proposed to the PHC by the system engineer to prevent reoccurrence. Extent Of Condition: the same/similar valve is used in several places on the CW make up and blowdown piping. Byron has a CW makeup and blowdown pipe, however it is not known if Byron has vacuum breakers and if so what type of vacuum breakers. A message was left for the Byron CW system engineer about this problem.

11-17 A2000-04389 The station's response to a December 1998 CW vacuum breaker valve (OCW060) failure (39223), Inadequate appears to have been inadequate. No evidence can be found to documenting any follow-response to 1998 CW up sampling, surveys or reporting requirements. PIF# A 1998-04324 details the station' vacuum breaker valve, response to the 1998 leak. This issue was discovered during the present root cause leak.

investigation for the CW vacuum breaker valve failure (OCWI136).

11-30 A2000-04465, Station was slow to implement event response guidelines, CWPI-NSP-AP-1-1, or NGG Slow response to Issues Management, OP-AA-101-503, for the CW blowdown vacuum breaker failure that implementing Event was discovered on 11/06/00. NGG Issues Management was not entered until 2+ days

Response

after discovery of the valve failure when rad sample results indicated detectible levels of Guidelines/NGG Issues particulate radioactivity from the spill.

Management procedure.

6-18 A2001-01806, Unauthorized Release Path? [#3 & 11 ]- OCW060 was found seeping water from between CW B/D Valve Leaking.

the vacuum breakerfloat and the Buna-N seal. Leakage appears to be about I gal/2 hours.

As discovered during the investigation of CR# A2000-04281, periodic maintenance of the circulating water blowdown vacuum breaker valves had not previously been up to the standards desired by the station. A campaign was initiated in Q2 2001 to repair/replace as necessary these vacuum breaker valves. When the vaults were opened, four were discovered to contain water (vaults housing OCW060, 0CW144, 0CW075 and 0CW078).

Radiological analysis of the water revealed 2 of the 4 vaults with radioactive material present in the water (OCW060 and 0CW078 showed activity).

31

Previous Events Previous Event Review 7-9 A2001-02016 A review of a root cause report titled "Circulating Water Blowdown Line Vacuum (56710), Weaknesses Breaker Failure Due To Low Stress, High Cycle Fatigue, Resulting In Flooding Of Owner Identified in Controlled Property And Discharge Outside Of NPDES Approved Path" determined that Documentation of RCR there were weaknesses associated with the report documentation (reference CR# A2000-For CW Blowdown 04281.and ATI# 38237). Although the report was well written, the review identified that Valves.

the description of the Corrective Actions to PreventRecurrence (CAPRS) lacked the clarity needed for mechanical maintenance to understand the full scope of work required to execute the CAPR. Furthermore, it appears that scheduling issues were not fully considered when the due dates were set.

5-4 106767, Small OCW060, CW blowdown vacuum breaker, was identified as having seepage from the vent leak identified from on the air release valve, (air release valve is part of the entire vacuum breaker assembly OCW060 blowdown valve but sits adjacent to the main vacuum breaker valve). Main vacuum breaker valve assembly (VB-3) appeared satisfactory, no leakage. Water level in pit was 30" from top of manhole. No evidence of leakage outside of the manhole was noticed. Water in manhole/pit appears to be a normal condition associated with groundwater infiltration into the manhole.

8-20 172376, CW Main vacuum breaker seat has 1 gpm leak. Water is draining to vacuum breaker pit only Blowdown Vacuum no area flooding is occurring.

Breaker 0CW138 has 1 gpm leak (VB-4) 8-27 173204, Modification testing associated with EC336241 was performed on 8/25/03. The testing OWX26T release with required a release to be performed from the OWX26T release tank while blowdown flow suspected leakage from was established at -25,000 gpm. Seat leakage from the 0CW138 blowdown vacuum OCW138 VB-4.

breaker most likely occurred during the time that blowdown flow was at a flow rate of 25,000 gpm. Based on field observations performed on 8/21/03 and 8/27/03 the suspected leakage from the OCW 138 during the time of the OWX26T release was between.25 and 1 gpm, (Note: 0WS26T release occurred between 0630 and 0710 on 8/25/03, Release package L03-104.) Field observations of the 0CW138 were also performed at blowdown flow rates of between 12,000 & 14,000 gpm. These observations indicate that no leakage occurs at these lower flow rates and that the vacuum breaker appears to be open, (Note:

OCW138 open with no leakage indicates that the blowdown pipe is not completely full at the lower flow rates.)

8-29 173688, Water While performing the annual vacuum breaker surveillance we discovered water in the pit in Vacuum Breaker Pit for containing breaker OCW060. WR # 00110407 was initiated.

breaker OCW060 [#3].

9-11 175241, When CW blowdown was increased per BwOP CW-12 (to approximately 22,000 gpm, 0CM138 leaking at high 0CW138 was discovered to be leaking at 5 drops per minute.

CW blowdown flow rates

[#4].

11-17 274328, While performing OBwOS CW-A1 (CW System B/D and M/U Vacuum Breaker Vacuum Breaker Inspection) vacuum breaker 0CW069 was popping/leaking. The leakage was small and 0CW069 Is Leaking [#8].

contained within the vacuum breaker's valve pit. Per the Limitations and Actions of the procedure the Shift Manager and RP were notified immediately. Chemistry was notified of the potential for exceeding a limit for NPDES. System Engineering was contacted for guidance and it was determined that the 0CW068 valve would be maintained closed to isolate the vacuum breaker leakage. The System Engineer recommended that two adjacent vacuum breakers not be isolated with CW blowdown in operation. EST (37096)

(Equipment status tag) was generated to document the abnormal position.

32

Previous Events Previous Event Review 4-25 328451, Tritium Two samples results from onsite property located on the downstream side of the culvert at Indicated In Samples the old A entrance gate came back from the vendor with tritium indicated on the results.

Taken From Onsite Specifically, the analysis results from Environmental Inc. Midwest Laboratory (EIML)

Culvert.

indicated results of 539 +/-121 pCi/L tritium (sampled on 03/24/05) and 582.963 +/-

112.314 pCi/L tritium (sampled on 04/07/05).

5-18 336401, CW CW BD Vacuum breaker 0CW058 pilot valve leaking 20 DPM. Need WR to repair.

BD Vacuum Breaker 0CW058 Pilot Valve Leaking 20 DPM [#1].

5-24 338111, While performing ER-BR-400-101, OCW 140 blowdown vacuum breaker valve was OCW140 Blowdown observed to have continuous seepage of water from the valve float/seat area. The leakage Vacuum Breaker Valve is small enough to be contained within the vacuum breaker valve pit with approximately Leaking From Seat [#6.

one foot of standing water in the pit.

9-8 371248, NRC During NRC debrief on 8/31/05, there was discussion regarding the CW blowdown Questions On Previous vacuum breaker, 0CW058, leakage that was identified in May 2005 (Reference IR Actions With CW B/D 336401). A previous root cause was performed for vacuum breaker failures that occurred vacuum breakers.

in 2000. The NRC question is: Subsequent to 0CW058 leakage identified in May 2005, were the root cause actions reviewed for adequacy? If so, what was the conclusion?

11-30 428868, Elevated levels of tritium have recently been identified in certain onsite groundwater Elevated Tritium Levels sampling wells. The exact source has not been located nor has the source been In Onsite Monitoring determined to be active or historical.

Wells.

NOTE: Review was revalidated on 02/16/06 with no new relevant events found.

33

Corrective Actions to Prevent Recurrence (CAPRs):

Root Cause Being Corrective Action to Prevent Recurrence Owner Due Date Addressed (CAPR)

Causal Factor 1, Root (CAPR 1: ATI# 38237-08, 38237-17, & 38237-18)

A8930I" Completed Cause 1: The root cause Institute a Preventative Maintenance Program and 03/01/01 of the significant leaks in system modifications, which are complete and have 1998 and 2000 is been verified to be effective in preventing major valve documented in Root failures that result in large volume spills.

Cause Report (RCR) 38237, which determined

[NOTE: On January 15, 2006, a leak occurred on VB-that the Circulating Water 7 due to failure of an internal guide and was (CW) Blowdown (B/D) documented on IR# 442540. (See analysis section of Vacuum Breaker (VB) how this issue is addressed) CA-29 will review EACE Valves had inadequate 442540 to ensure corrective actions from 2000 RCR preventative maintenance 38237 & RCR 428868 are still effective.]

programs and inadequate design configuration.

Braidwood Station presently performs daily walkdowns of the blowdown vacuum breakers to verify Failed Barrier (FB-20) that no leakage is occurring.

Piping/Valves equipment failures Causal Factor 2, Root (CAPR 2)

1) A8901H3
1) 04/03/06 Cause 2: The root cause
1) The Braidwood Tritium Remediation Team will of the small leaks, which determine the methodology and implement the plan for both preceded and future radiological releases, including leakage succeeded the 1998 and standards. (Note: AR 435383435383 2000 leaks, was that the need for a near zero (CAPR 3)
2) A8923 and
2) Completed.

leakage standard was not

2) HU-AA-102 and HU-AA-1212, Technical Human A8961 (approved (Approved for identified, due to a lack of Performance Practices and Technical Task Risk/Rigor for use at use at Technical Assessment, Pre-Job Brief, Independent Third Party Braidwood)

Braidwood in Rigor/Questioning Review, and Post-Job Brief procedures have been 07/09/04 and Attitude.

instituted to improve technical rigor, questioning 07/14/04) attitude, and attention to detail.

CF-5 Regulations/Oversight FB-33 Weak management review and oversight of spill response activities.

34

Root Cause Being Corrective Action to Prevent Recurrence.

Owner Due Date Addressed (CAPR)

OwnerDueDat Causal Factor 3, Root (CAPR 4)

NCS 6/20/06 Cause 3:

Develop and implement Standard Exelon procedures to A8015ENV The first root cause for provide integrated and detailed spill and leak response the ineffective response requirements to ensure full compliance with State and was a lack of integrated.

Federal laws and regulations and integrate Exelon procedural guidance to resources to respond to radiological leaks and spills.

ensure proper recognition, evaluation, and timely mitigation of the radiological spill events.

CF-3 Procedures Failed Barrier (FB)-l BwAP 750-4 FB-2 BwAP1 100-16 FB-3 NSP-RP-6101 FB-4 RP-AA (no specific procedure)

FB-6 BwOA ( no specific procedure FB-12 ER-BR-400-101 FB-13 OBwOS CW-A1 FB-14 EN-AA Causal Factor 6 Notification FB-30 Notification to other site departments Causal Factor 4, Root (CAPR 3)

1) A8923 and
1) Completed Cause 4. A second root
1) HU-AA-102 and - HU-AA-1212, Technical Human A8961 (approved (Approved for cause for the ineffective Performance Practices and Technical Task Risk/Rigor for use at use at response was weak Assessment, Pre-Job Brief, Independent Third Party Braidwood)

Braidwood in management review and Review, and Post-Job Brief procedures have been 07/09/04 and oversight of spill instituted to improve technical rigor, questioning 07/14/04.

response activities, attitude, and attention to detail.

(CAPR's 3 and 5)

(CAPR 5)

2) A8016NGGOP
2) 04/21/06 CF-5
2) OP-AA-106-101-1002, Exelon Nuclear Issues Regulations/Oversight Management, will be revised to: 1) improve Corrective FB-33 Weak management Action Program (CAP) controls of Issues Management review and oversight of teams, 2) utilize the tools and techniques of the Exelon spill response activities.

HU-AA-102 and HU-AA-1212, Technical Human Performance Practices and Technical Task Risk/Rigor Assessment, Pre-Job Brief, Independent Third Party Review, and Post-Job Brief procedures, 3) strengthen reporting requirements to affected station Senior Management, and 4) define affected station Senior Management responsibilities for oversight and challenge of events and issues from initial identification to final disposition.

35

Effectiveness Reviews (EFRs):

Effectiveness CAPR / CA being addressed Review Action Owner Due Date Causal Factor 1, Root Cause 1: The root cause of the (EFR 1: 00038237-10)

A8930Tr Completed significant leaks in 1998 and 2000 is documented in Perform effectiveness 05/22/2002 Root Cause Report (RCR) 38237, which determined review of CAPR's under that the Circulating Water (CW) Blowdown (B/D)

ATI# 00038237-Vacuum Breaker (VB) Valves had inadequate 7,8,10,17-20 preventative maintenance programs and inadequate design configuration.

EFR assignment for CAPRs # 2, 3, 4, & 5:

EFR 2 A8932CHEM 6/20/07 (CAPR 2) The Braidwood Tritium Remediation Team Perform effectiveness will determine the methodology and implement the review of CAPR(s) under plan for future radiological releases, including leakage ATI#428868 for CAPR#

standards.

2,3,4,5 (CAPR 3) HU-AA-102 and HU-AA-1212, Technical Human Performance Practices and Technical Task Risk/Rigor Assessment, Pre-Job Brief, Independent Third Party Review, and Post-Job Brief procedures have been instituted to improve technical rigor, questioning attitude, and attention to detail.

(CAPR 4) Develop and implement Standard Exelon procedures to provide integrated and detailed radiological spill and leak response requirements to ensure full compliance with state and federal laws and regulations and integrate Exelon resources to respond to radiological leaks and spills.

(CAPR 5) OP-AA-106-101-1002, Exelon Nuclear Issues Management, will be revised to: 1) improve Corrective Action Program (CAP) controls of Issues Management teams, 2) utilize the tools and techniques of the Exelon HU-AA-102 and HU-AA-1212, Technical Human Performance Practices and Technical Task Risk/Rigor Assessment, Pre-Job Brief, Independent Third Party Review, and Post-Job Brief procedures, 3) strengthen reporting requirements to affected station Senior Management, and 4) define affected station Senior Management responsibilities for oversight and challenge of events and issues from initial identification to final disposition.

MRC assignment for EFR CA-1 A8932CHEM 6/27/07 Present the EFR to MRC.

36

Corrective Actions:

Cause Being Addressed Corrective Action (CA) or Action item (ACIT)

Owner Due Date Causal Factor 5 CA-2 A8961 08/30/06 Regulations/Oversight Develop a case study of this event. Provide initial and Failed Barrier (FB-33) continuing training for appropriate Braidwood Station and Weak management Exelon Corporate Management personnel.

review and oversight of radiological spill CA-3 A8961 07/21/06 response activities.

Generate a training request for Dynamic Learning Activity (DLA) for all Braidwood Duty Team personnel using 2000 release conditions and revised response and reporting procedures implemented in CAPR4. Create additional assignments as warranted. Report training request action determinations to STC.

CA-4 NCS 05/29/06 Generate a training request to review other potential leaks A8076CHEM beyond tritium to address extent of condition regarding Exelon management's control of hazardous material spills.

If deficiencies are noted, write IR's to have those deficiencies addressed. Report training request action determinations to STC.

Causal Factor 5.

CA-5 NCS 05/29/06 Regulations/ Oversight Revise the Midwest ODCM and/or program procedures to A8076CHEM FB-27 Title 35 IAC incorporate the State of IL requirement of <20,000 pCi/L part 620 groundwater of tritium for groundwater (35 IAC 620.410.e).3)) and the quality State of IL requirement for non-degradation (35 IAC 620.301.a))

CA-6 NCS 05/29/06 Revise the ODCM and/or program procedures as A8076CHEM warranted to incorporate the State of PA requirements for radioactivity in groundwater.

CA-7 NCS 05/29/06 Revise the ODCM and/or program procedures as A8076CHEM warranted to incorporate the State of NJ requirements for radioactivity in-groundwater CA-8 NCS 05/29/06 Clearly define to each station (extent of condition), the A8076CHEM changes to the ODCM based on review of Illinois laws governing radioactive contamination of groundwater (potable water). Assign additional corrective actions to ensure site's ODCM reflects and implements applicable regulations.

CA-9 NCS 05/29/06 Clearly define to each station (extent of condition), the A8076CBEM changes to the ODCM based on review of Pennsylvania laws governing radioactive contamination of groundwater (potable water). Assign additional corrective actions to ensure site's ODCM reflects and implements applicable regulations.

37

Cause Being Addressed Corrective Action (CA) or Action item (ACIT)

Owner Due Date Causal Factor 5.

CA-10 NCS 05/29/06 Regulations/ Oversight Clearly define to each station (extent of condition), the A8076CHEM Failed Barrier (FB)-27 changes to the ODCM based on review of New Jersey Title 35 IAC part 620 laws governing radioactive contamination of groundwater groundwater quality (potable water). Assign additional corrective actions to ensure site's ODCM reflects and implements applicable regulations.

Causal Factor 3, CA-1 NCS 05/29/06 Procedures Corporate Regulatory Assurance to perform an extent of A8002RAPO condition review regarding ODCM, REMP, RETS and FB-7 LS-AA-1020 &

state regulations for needed changes to the Reportability 1110 Reportability Manual and create additional actions as required.

Manual CA-12 NCS 4/14/06 FB-8 LS-AA-1020 &

Corporate Regulatory Assurance to revise the A8002RAPO 1110 Reportability Reportability Manual for reporting requirements of 35 Manual IAC 611/620 Groundwater Tritium Release Path, 20,000 pCi/L limitations, and Illinois SB241 Community Right to FB-9 LS-AA-1020 &

Know requirements.

1110 Reportability Manual Causal Factor 5, CA-13 NCS 06/28/06 Regulations/ Oversight Revise CY-AA-170-000 and associated procedures to A8076CHEM require audits of the ODCM against applicable laws and FB-28 Corporate regulations at.an acceptable frequency. Review the need Oversight for revision to include State regulations into Step 4.2.1 basis of the ODCM. Create additional actions as warranted.

Causal Factor 3, CA-14 NCS 4/14/06 Procedures Review the process by which the company becomes aware A8015 ENV FB-1 1 LS-AA-1020 &

of new environmental laws and regulations for 1110 Reportability radiological and non-radiological issues and how they are Manual integrated and communicated into company policies, programs, and procedures. Assign additional actions as necessary, if process changes are needed.

Causal Factor 5, Regulations/Oversight FB-26 Title 35 IAC part 611 groundwater quality FB-27 Title 35 IAC part 620 groundwater quality Causal Factor 6, Notification FB-31 Notice to sites of new State Regulations 38

Programmatic/Organizational Issues:

Programmatic and Organizational Corrective Action (CA) or Action Item (ACIT)

Owner Due Date Weaknesses Causal Factor 5, CA 15 NCS 5115/06 Regulations/Oversight Evaluate the groundwater and food crop pathway per A8076CHEM ODCM Table 12.5-1 Section 3.a note (6). Assign Failed Barrier (FB)-24 additional actions as necessary, if the pathway is ODCM requires credible.

evaluation of groundwater pathway if CA 16 NCS 5/15/06 credible Revise the Site specific portions of the ODCM to A8076CHEM incorporate the new monitoring wells as determined by FB-25 ODCM requires the ODCM Environmental Specialist to be credible evaluation of groundwater (well water) monitoring sources into the groundwater pathway if ODCM Table 11-1 Section 3.a note (6) and ODCM credible REMP Table 12.5-1 Section 3a Note (6).

Causal Factor 7, Training CA 17 A8931RP 3/14/06 Generate TR to develop appropriate training for the RP FB-21 Certification of management and technician level of knowledge Chemistry personnel regarding the CW B/D system and the radioactivity expected to be present. Refer to the Root Cause Report FB-22 Licensed and to be used as a case study. If the TR is rejected, report Non-licensed Operator out to Senior Training Council (STC).

initial and requalification CA 18 A8932CHEM 3/14/06 training Generate TR to develop appropriate training for the chemistry management and technician level of FB-23 Certification of knowledge regarding the CW B/D system and the RP/HP radioactivity expected to be present. Refer to the Root Cause Report to be used as a case study. If the TR is rejected, report out to Senior Training Council (STC).

CA 19 A8910OPS 3/14/06 Generate TR to develop appropriate training for the operations personnel level of knowledge regarding the CW B/D system and the radioactivity expected to be present. Refer to the Root Cause Report to be used as a case study. If the TR is rejected, report out to Senior Training Council (STC).

Causal Factor 3, CA 20 A8910OPS 5/29/06 Procedures Ops to add precautions to BwOP CW-12, BwOP WX 526TI, & BwOP WX-501TI for release shutdown on FB-15 BwOP CW-12 leak to environment and for the release restrictions FB-16 BwOP WX-526T1 dealing with Reportability Manual Section RAD 1.21 FB-17 BwOP WX-501T1 (i.e.: 100 Ci. limit on tritium releases over a 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> period).

Causal Factor 3 CA 21 A8931RP 6/1/06 Procedures:

RP manager to present to peer group changes to FB-3, NSP-RP-6101, 50.75(g) procedure to clearly address actions necessary "10 CFR 50.75(g)(1) for tritiated water spills, including evaluation for dose Documentation assessment to the public and initiate follow-up actions Requirements" as appropriate to track necessary procedure changes.

39

OTHER ISSUES:

Other Issues Identified During the Investigation Corrective Action (CA) or Action Item (ACIT)

Owner Due Date Other issues: Alarms/

CA-22 A8930TT 03/24/06 Annunciators Braidwood System Engineering to review operation of IR435383 the CW. blowdown system and determine the optimum Failed Barrier (FB)-I 8 monitoring scope and frequency of inspection PM's Leak detection of and walk downs for the System. If applicable, identify vacuum breakers gaps and create additional ATI's as required.

Other issues:

CA-23 A8930TI 07/14/06 Alarms/Annunciators Braidwood System Engineering to research and IR435383 evaluate passive vacuum breaker replacement options FBý18 Leak detection of and present findings to PHC for approval if the CW vacuum breakers Blowdown system will be used for radwaste releases in the future. If no action is taken, present this fact to MRC.

Other issues: Alarms/

CA-24 A8930TT 07/14/06 Annunciators System Engineering to work with Design Engineering IR435383 to research and evaluate viable remote monitoring FB-19 Alarms and instrumentation systems that can detect lower level Annunciators external leakage from the blowdown system and automatically notify Braidwood Operations if the CW blowdown system will be used for radiological releases. If no action is taken, present this fact to MRC.

Other issues: Work CA-25 A8931RP 3/10/06 Orders:

RP to provide information to Work Planning so that a work standard can be created for work activities that FB-32 involve potentially tritiated water. This information Model PM work orders will be used to update PM model work orders and and current work orders current work orders involving potentially tritiated for B/D vacuum water.

breakers Causal Factor 3 CA-26 NCS 5/29/06 Procedures Corporate Work Control to implement revision of WC-A8035OUT AA-106 to incorporate a higher work priority for FB-5 response to unplanned low-level radioactive water WC-AA-106 being released to the environment and repairs to Attachment I implies a release path monitors.

"B2" if increased sampling Other issues: Work CA-27 A8925PLN 4/10/06 Orders Using the information provided by RP, create a work standard to be used for work activities that involve FB-32 Model PM work potentially tritiated water and update PM model work orders and current work orders and current work orders involving potentially orders for B/D vacuum tritiated water (RWP, sample for tritium, instructions breakers for pumping tritiated water).

40 C-

Other Issues Identified During the Investigation Corrective Action (CA) or Action Item (ACIT)

Owner Due Date Causal Factor 6, ACIT-28 A8921NOA 03/28/06 Notification Discuss this RCR with the Corporate NOS Peer Group to evaluate changing the NOS auditing template Failed Barrier (FB)-29 standard for the ODCM Program. Document results NOS Audit NOSA-and assign additional actions as required.

BRW-05-08 (AR 287718287718 November 22, 2005 Causal Factor 1, Root CA-29 A8930T" 03/28/06 Cause 1 Review EACE 00442540 to ensure corrective actions from 2000 RCR 38237 & RCR 428868 are still effective Causal Factor 3, CA-30 A8931RP 11/28/06 Procedures Review 50.75(g) files to ensure tritium and or any other isotopes are included for all blowdown vacuum FB-3 NSP-RP-6101 breaker water events and perform 50.75(g) evaluation for all blowdown vacuum breakers not previously completed.

Other issues: Procedures CA-31 A8930TT Per CA BwOP CW-12 was revised to undo water hammer process FB-20 Piping/valves corrective actions from the 2000 root cause report.

equipment failures Issue to be addressed under IR 45338 1.

01 fl, ODCM IR 453638 Tritium Remediation Team review the A8901H3 4/01/06 Reportability review for reportability associated with 12.5.1lA.2 to determine environmental samples applicability to the environmental groundwater sampling that is occurring as part of their investigation.

01 gI, No clear CA-32 NCS 6/20/06 delineation of Update Exelon Management Model to define A8015ENV responsibilities between responsibilities for low level radioactive spills.

corporate Environmental and Chemistry for low level radioactive spills.

41

Communications Plan:

Lessons Learned to Communication Plan Action Owner Due Date be Communicated Elevated tritium levels in NER 1 A8932CHEM Complete onsite monitoring wells; Submit Preliminary NER (NER 1) for this event Elevated tritium levels in NNOE 1 A8932CHEM Complete onsite monitoring wells; Submit preliminary NNOE (NNOE 1) for this event.

Blowdown line, CA 33 A8932CHEM 03/14/06 Secondary System Create a station alignment slide that discusses the root Condensate and other cause and actions for station personnel when they low level tritium system discover liquid spills/leaks or liquid in areas where-leaks impact to State and there should not be liquid.

Federal regulations for ground/drinking water.

Elevated tritium levels in NER update (NER 2) per ATI 428868-12 A8932CHEM 03/03/06 onsite monitoring wells; Submit supplemental NER (NER 2) for this event Spills of liquids with low which include a requirement for all Exelon sites to; level radioactivity may

1) Review all historical radiological spills/leaks to site impact State and Federal property outside of the RCA.

regulations.

2) Verify tritium concentrations have been determined for the radiological spills/leaks or perform sampling to determine tritium concentrations for each of the radiological spills/leaks.
3) Determine impact of spilled tritium on environment.
4) Create additional actions as warranted to insure compliance with all Federal and State regulations and laws.

Elevated tritium levels in Promulgate NER 2 to Exelon Nuclear Fleet to include:

A8076CHEM 03/13/06 onsite monitoring wells; Submit supplemental NER for this event which include Spills of liquids with low a requirement for all Exelon sites to; level radioactivity may

1) Review all historical radiological spills/leaks to site impact State and Federal property outside of the RCA.

regulations

2) Verify tritium concentrations have been determined for the radiological spills/leaks or perform sampling to determine tritium concentrations for each of the radiological spills/leaks.
3) Determine impact of spilled tritium on environment Elevated tritium levels in NNOE update (NNOE 2) per ATI 428868-13. Submit A8932CHEM 03/10/06 onsite monitoring wells; supplemental NNOE (NNOE 2) for this event Spills of liquids with low level radioactivity may impact State and Federal

-regulations.

42

Root Cause Report ATTACHMENTS Title Notes 1

Charter Revision 1 for improved scope clarity.

2 Barrier Analysis 3

Cause & Effect Analysis 4

E&CF Chart 5

Change Analysis 6

Circ water blowdown system background information 7

Tritium plume map 8

Review of Exelon Hazmat spill response procedures 9

Reportability Manual - LS-AA-1020 and LS-AA-1110 10 Summary of Applicable State, Federal, and Offsite Dose Calculation Manual (ODCM)

Regulations and Requirements for Tritium Releases to the Environment 11 Root Cause Report Quality Checklist 12 VB-2 and VB-3 detailed timelines 43 Page 1 of 3 LS-AA-1 25-1001 Revision Root Cause Investigation Charter (rev 1)

Tritium Release from Braidwood Station with a Potential to Affect the Public Condition Report #:

Sponsoring Manager:

Team Investigator(s):

428868 Janice Kuczynski, Chemistry Manager Names Position Commitment

.,Jason Eggart

'Tom Leffler Randy Kalb IKim Aleshire Glen Vickers Scott Kirkland Jim Crawford John Gumnick Mike Miller Jeff Burkett

) Dan Stroh

,Scott Sklenar Braidwood Chemistry Lead Investigator Root Cause Qualified Investigator Dresden Chemistry Investigator Braidwood EP (ODCM) Investigator LaSalle RP Investigator Quad Cities Investigator Braidwood Maintenance Investigator Corporate RP (CHP) Investigator Braidwood Operations Braidwood Operations Braidwood Engineering Hydrologist Full Time Full Time Part Time Full Time Full Time Part Time Full Time Part-Time Part Time Part Time Full-Time Part-Time Scope:

The scope of the root cause investigation is twofold:

The first focus of this root cause team is to determine the root cause(s) of the Tritium releases from Braidwood Station, which, although low level, had a potential to affect the public. This causal determination should include the large volume leaks, which occurred in 1998 and in 2000, as well as the smaller volume leaks, which both followed and preceded the 1998 and 2000 leaks. The responsibility for identifying and operationalizing corrective actions to prevent future unacceptable tritium releases to the environment is being addressed by the Braidwood Tritium Remediation Team under AR 435383435383

44 Page 2 of 3 This root cause team remains responsible for identifying corrective actions to address organizational weaknesses contributing to or causing the releases described above.

The second focus of this root cause team is to evaluate the effectiveness of Braidwood's response to the circulating water Blowdown leaks, which deposited tritiated water on the ground during 1998 and 2000 as well as during the smaller volume leaks, which both followed and preceded the 1998 and 2000 leaks. If this evaluation determines that Braidwood's response actions were not effective, this root cause team will determine the root cause and appropriate corrective actions for those ineffective response actions. The investigation will review response procedures, regulations, environmental impacts, and managerial effectiveness. As part of this second focus item, the team will review the response to known spills in 1998, 2000 and similar IRs. A review of year 2000 Root Cause corrective action effectiveness will be performed. Specifically, the team will look for any evidence that the actions to prevent recurrence were not effective. An E&CF Chart will be utilized for Change Analysis and Barrier Analysis. Tap Root Analyses will also be utilized.

To accomplish a timely report delivery, support will be required as noted above in Engineering, Hydrology, Maintenance, Operations, Offsite Dose Assessment, and Technical Writing.

The responsibility for remediating the existing condition of detectable tritium in groundwater on and in the vicinity of Braidwood Station is not the responsibility of this root cause team. Remediation of the existing condition of detectable tritium in groundwater on and in the vicinity of Braidwood Station is being addressed by the Braidwood Tritium Remediation Team under AR 435383435383

Interim Corrective Actions:

As described above, an Issues Management Team (the Braidwood Tritium Remediation Team) has been formed to manage the recovery.

Additional Sampling is being performed and analyzed to fully define the affected areas.

The discharge piping is being reviewed for integrity.

Remediation plans will be developed and implementation initiated.

The Braidwood Tritium Remediation Team will maintain communications with Exelon, Regulatory personnel, the public, and INPO.

45 Page 3 of 3 Root Cause Report Milestones:

1.

Event Date

2.

Screening Date

3.

Completion of Charter (2 Days from MRC) [-03]

3a.

Completion of Charter revision

4.

Status Briefing for Charter [-14]

5.

Two Week Update & Draft RCR for Reviews [-07]

6.

MRC Update & Draft RCR for Reviews [-08]

7.

CAPCo Reviews of RCR [-15]

8.

Collegial Reviews of RCR [-15]

9.

MRC Update & Draft RCR for Reviews [-09]

10.

Sponsoring Manager Report Approval [-14]

11.

Root Cause delivered to PORC

12.

Review by PORC [-05]

13.

Revised Root Cause Report delivered to PORC

14.

Revised Root Cause Report Reviewed by PORC

15.

Final Root Cause Investigation Due Date [-04]

Prepared By:, Tom Leffleri Root Cause Qualified 1,vestigatov (Name)

(11/30/05)

(12/07/05)

(12/09/05)

(02/08/06)

(12/14/05)

(12/21/05)

(12/28/05)

(12/29/05)

(12/29/05)

(01/04/06)

(01/04/06)

(01/24/06)

(01/26/06)

(02/20/06)

(02/22/06)

(02/23/06) 02/06/06 (Date)

Approved By:

Carl B. Dunn, Training Director 02/08/06 For (Sponsoring Manager)

(Date) 46 Page 1 of 11 Barrier Analysis Failed or ineffective barrier How Barrier Failed Why Barrier Failed Corrective action to Restore Barrier to Effectiveness Procedures CF 3_

BwAP 750-4

- Hazmat was not Lack of knowledge of

- Develop and implement Standard Exelon procedures to provide integrated and entered Title 35 IAC part 620 detailed spill and leak response requirements to ensure full compliance with state Failed Barrier 1 groundwater quality and federal laws and regulations and integrate Exelon resources to respond to (FB-1) radiological leaks and spills. (CAPR 4)

- Procedure does not

- See Training Failed Barrier actions prompt radiological response BwAPll00-16

- Hazmat was not Lack of knowledge of

-Develop and implement Standard Exelon procedures to provide integrated and (FB-2) entered Title 35 IAC part 620 detailed spill and leak response requirements to ensure full compliance with state groundwater quality and federal laws and regulations and integrate Exelon resources to respond to radiological leaks and spills. (CAPR 4)

Procedure does not

-See Training Failed Barrier-actions prompt radiological response NSP-RP-6101 50.75(g) does not Lack of knowledge of

- Develop and implement Standard Exelon procedures to provide integrated and (FB-3) clearly address Title 35 IAC part 620 detailed spill and leak response requirements to ensure full compliance with state tritium groundwater quality and federal laws and regulations and integrate Exelon resources to respond to radiological leaks and spills. (CAPR 4)

-RP manager to present to peer group changes to 50.75(g) procedure to clearly address actions necessary for tritiated water spills, including evaluation for dose assessment to the public and initiate follow-up actions as appropriate to track necessary procedure changes. (CA-21)

-Review 50.75(g) files to ensure tritium and or any other isotopes are included for all blowdown vacuum breaker water events and perform 50.75(g) evaluation for all blowdown vacuum breakers not previously completed. (CA-30)

-See Training Failed Barrier actions 47 Page 2 of 11 Barrier Analysis Failed or ineffective barrier How Barrier Failed Why Barrier Failed Corrective action to Restore Barrier to Effectiveness RP-AA No guidance for low Lack of knowledge of Develop and implement Standard Exelon procedures to provide integrated (FB-4) level spills Title 35 IAC part 620 and detailed spill and leak response requirements to ensure full compliance groundwater quality with state and federal laws and regulations and integrate Exelon resources to respond to radiological leaks and spills. (CAPR-4)

- See Training Failed Barrier actions WC-AA-106 WC called issues Lack of knowledge of

- See Training Failed Barrier actions Attachment I implies a "C", not recognizing Title 35 IAC part 620

- Corporate Work Control to implement revision of WC-AA-106 to "B2" if increased that sampling for groundwater quality incorporate a higher work priority for response to low level radioactive water sampling tritium would be being released to the environment. (CA-26)

(FB-5) required BwOA No guidance for low Lack of knowledge of Develop and implement Standard Exelon procedures to provide integrated (Radiological spill level spills Title 35 IAC part 620 and detailed spill and leak response requirements to ensure full compliance procedure does not groundwater quality with state and federal laws and regulations and integrate Exelon resources to exist) respond to radiological leaks and spills. (CAPR-4)

(FB-6)

- See Training Failed Barrier actions LS-AA-1020 & 1110 Does not reflect Lack of knowledge of

-Corporate Regulatory Assurance to perform an extent of condition review Reportability Manual ODCM REMP/RETS Title 35 IAC part 620 regarding ODCM, REMP, RETS and state regulations for needed changes to (FB-7) reporting groundwater quality the Reportability Manual and create additional actions as required. (CA-1l) requirements

-Corporate Regulatory Assurance to revise the Reportability Manual for reporting requirements of 35 IAC 611/620 Groundwater Tritium Release Path, 20,000 pCi/L limitations, and Illinois SB241 Community Right to Know requirements. (CA-12)

- See Training Failed Barrier actions 48 Page 3 of 11 Barrier Analysis Failed or ineffective barrier How Barrier Failed Why Barrier Failed Corrective action to Restore Barrier to Effectiveness LS-AA-1020 & 1110 Does not reflect 35 Lack of knowledge of

-Corporate Regulatory Assurance, to perform an extent of condition review Reportability Manual IAC 620 Title 35 IAC part 620 regarding ODCM, REMP, RETS and state regulations for needed changes to (FB-8)

Groundwater Tritium groundwater quality the Reportability Manual and create additional actions as required. (CA-11)

Release Path, 20,000

-Corporate Regulatory Assurance to revise the Reportability Manual for pCi/L limitations reporting requirements of 35 IAC 611/620 Groundwater Tritium Release Path, 20,000 pCi/L limitations, and Illinois SB241 Community Right to Know requirements. (CA-12)

- See Training Failed Barrier actions LS-AA-1020 & 1110. ENV 3.26 does not Lack of knowledge of

-Corporate Regulatory Assurance to perform an extent of condition review Reportability Manual clearly warn of Title 35 IAC part 620 regarding ODCM, REMP, RETS and state regulations for needed changes to (FB-9) tritium groundwater groundwater quality the Reportability Manual and create additional actions as required. (CA-1 1) quality standards

-Corporate Regulatory Assurance to revise the Reportability Manual for reporting requirements of 35 IAC 611/620 Groundwater Tritium Release Path, 20,000 pCi/L limitations, and Illinois SB241 Community Right to Know requirements. (CA-12)

- See Training Failed Barrier actions LS-AA-1020 & 1110 RAD 1.21, 10OCi Lack of knowledge of

- See Training Failed Barrier actions Reportability Manual tritium 24h release tritium amounts released (FB-10) limitation not checked LS-AA-1020 & 1110 SAF 1.9 New Right No program for review Review the process by which the company becomes aware of new Reportability Manual to Know legislation and promulgation of new environmental laws and regulations for radiological and non-radiological (FB-11) not reflected, laws.

issues and how they are integrated and communicated into company policies, programs, and procedures. Assign additional actions as necessary, if process changes are needed. (CA-14) 49 Page 4 of 11 Barrier Analysis Failed or ineffective barrier How Barrier Failed Why Barrier Failed Corrective action to Restore Barrier to Effectiveness ER-BR-400-101 No precaution for Lack of knowledge of

-Develop and implement Standard Exelon procedures to provide integrated Engineering tritium groundwater Title 35 IAC part 620 and detailed spill and leak response requirements to ensure full compliance Walkdown PM concern groundwater quality with state and federal laws and regulations and integrate Exelon resources to Procedure respond to radiological leaks and spills.

(FB-12)

(CAPR-4)

- See Training Failed Barrier actions OBwOS CW-A1 OPS No precaution for Lack of knowledge of Develop and implement Standard Exelon procedures to provide integrated Walkdown PM tritium groundwater Title 35 IAC part 620 and detailed spill and leak response requirements to ensure full compliance Procedure concern groundwater quality with state and federal laws and regulations and integrate Exelon resources to (FB-13) respond to radiological leaks and spills. (CAPR-4)

- See Training Failed Barrier actions EN-AA-Environmental No guidance for Lack of knowledge of

-Develop and implement Standard Exelon procedures to provide integrated procedures radiological spills Title 35 IAC part 620 and detailed spill. and leak response requirements to ensure full compliance (FB-14) that can get to groundwater quality with state and federal laws and regulations and integrate Exelon resources to drinking water respond to radiological leaks and spills. (CAPR-4) supplies

-See training failed actions barrier actions BwOP CW-12 No shutdown Lack of knowledge of

- Ops to add precautions to BwOP CW-12, BwOP WX-526TI, & BwOP WX-(FB-15) precautions during a Title 35 IAC part 620 501TI for release shutdown on leak to environment and for the release release for a leak in groundwater quality restrictions dealing with Reportability Manual Section RAD 1.21 (i.e.: 100 the blowdown system Ci. limit on tritium releases over a 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> period). (CA-20)

-See training failed barrier actions BwOP WX-526TI, No shutdown Lack of knowledge of

- Ops to add precautions to BwOP CW-12, BwOP WX-526TI, & BwOP WX-(FB-16) precautions during a Title 35 IAC part 620 501TI for release shutdown on leak to environment and for the release release for a leak in groundwater quality restrictions dealing with Reportability Manual Section RAD 1.21 (i.e.: 100 the blowdown system Ci. limit on tritium releases over a 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> period). (CA-20)

-See training failed barrier 50 Page 5 of 11 Barrier Analysis Failed or ineffective barrier How Barrier Failed Why Barrier Failed Corrective action to Restore Barrier to Effectiveness BwOP WX-501TI No shutdown Lack of knowledge of Title 35 IAC part 620

- Ops to add precautions to BwOP CW-12, BwOP WX-526TI, (FB-17) precautions during a groundwater quality

& BwOP WX-501TI for release shutdown on leak to release for a leak in environment and for the release restrictions dealing with the blowdown system Reportability Manual Section RAD 1.21 (i.e.: 100 Ci. limit on tritium releases over a 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> period). (CA-20)

- See training failed barrier actions Alarms/

Other Issue Annunciators "a" Leak detection on Only performed Not often enough to detect leaks. System has Braidwood System Engineering to review operation of the CW vacuum breakers annually at the time inherent suspended materials in the CW, which lowdown system and determine the optimum monitoring scope (FB-18) of the 1998 event, can cause the valves to stick open, allowing nd frequency of inspection PM's and walk downs for the Recently performed tritiated water to be released.

,ystem. If applicable, identify gaps and create additional ATI's on semi-annual basis.

s required (CA-22)

Currently (Since Sept. 2005)

-Braidwood System Engineering to research and evaluate performed monthly passive vacuum breaker replacement options and present findings to PHC for approval if the CW Blowdown system will be used for radiological releases in the future (CA-23)

Alarms and Did not alarm Did not exist. Neither the Operations Department, System Engineering to work with Design Engineering to annunciators which is responsible for operating and monitoring research and evaluate viable remote monitoring (FB-19) the CW B/D System, nor Plant Engineering, which instrumentation systems that can detect lower level external has responsibility for managing the CW B/D leakage from the blowdown system and automatically notify System, recognized the need for, nor did they Braidwood Operations if the CW blowdown system will be pursue installation of a remote detection system used for radiological releases. (CA-24) for each vacuum breaker. Such a system may have allowed earlier detection and isolation of the leaks described in Table 1, which could have reduced environmental impact.

51 Page 6of 11 Barrier Analysis

'Failed or ineffective barrier How Barrier Failed Why Barrier Failed Corrective action to Restore Barrier to Effectiveness Preventative CF-1 maintenance/

design configuration Piping/Valves Water hammer events Changed BwOP-CW12 BwOP CW-12 revised to mitigate water-hammer - revision 14.

equipment failures and created a water (Completed, 01/19/01). Corrective actions reversed by a subsequent (FB-20) hammer issue revision.

Corrective actions to be addressed under IR 453381. (CA-31)

Inadequate R Lack of preventative Institute a Preventative Maintenance Program and system modifications, preventative maintenance program which are complete and have been verified to be effective in preventing maintenance for these valves major valve failures that result in large volume spills. (CAPR 1) programs and v

Valves were not inadequate design designed to handle configuration the water hammer events Training CF-7 Certification of No training on a Did not know Title 35 Generate TR to analyze the chemistry management and technician level of Chemistry personnel response to a liquid IAC part 620 groundwater knowledge regarding the CW B/D system and the radioactivity expected to (FB-21) radiological spill for Tritium concentration be present. Refer to the Root Cause Report to be used as a case siudy.

requirements of Title limits (CA-18) 35 IAC part 620 groundwater quality.

52 Page 7 of 11 Barrier Analysis Failed or ineffective barrier How Barrier Failed Why Barrier Failed Corrective action to Restore Barrier to Effectiveness Licensed and Non-No Environmental Did not know Title 35 Generate TR to analyze the operations personnel level of knowledge licensed Operator spill training for low IAC part 620 groundwater regarding the CW B/D system and the radioactivity expected to be present.

initial and level radioactive quality Refer to the Root Cause Report to be used as a case study. (CA-19) requalification training liquids (FB-22)

Certification of RP/HP Lack of cert guide for Did not know Title 35 Generate TR to analyze the RP management and technician level of (FB-23) low level radioactive IAC part 620 groundwater knowledge regarding the CW B/D system and the radioactivity expected to be liquid spills quality.

resent. Refer to the Root Cause Report to be used as a case study. (CA-17)

Regulations CF-5 ODCM requires Braidwood has Did not know Title 35 Evaluate the groundwater and food crop pathway per ODCM Table 12.5-1 evaluation of demonstrated a IAC part 620 groundwater Section 3.a note (6). Assign additional actions as necessary, if the pathway groundwater pathway if credible pathway tritium concentration is credible. (CA-15) credible limits (FB-24)

ODCM requires Braidwood has Did not know Title 35 Revise the Site specific portions of the ODCM to incorporate the new evaluation of demonstrated a LAC part 620 groundwater monitoring wells as determined by the ODCM Environmental Specialist to be groundwater pathway if credible pathway Tritium concentration credible groundwater (well water) monitoring sources into the ODCM Table credible limits 11-1 Section 3.a note (6) and ODCM REMP Table 12.5-1 Section 3a Note (FB-25)

(6).groundwater. (CA-16)

Title 35 IAC part 611 ODCM does not Did not know Title 35 Review the process by which the company becomes aware of new groundwater quality reflect state IAC part 611 groundwater environmental laws and regulations for radiological and non-radiological (FB-26) groundwater quality issues and how they are integrated and communicated into company policies, requirements programs, and procedures. Assign additional actions as necessary, if process changes are needed. (CA-14) 53 Page 8 of 11 Barrier Analysis Failed or ineffective barrier jHow Barrier Failed jWhy Barrier Failed Corrective action to Restore Barrier to Effectiveness Title 35 IAC part 620 groundwater quality (FB-27)

ODCM does not reflect state groundwater requirements.

Did not know Title 35 IAC part 620 groundwater quality standards.

Revise the Midwest ODCM and/or program procedures to incorporate the State of IL requirement of <20,000 pCi/L of tritium for groundwater (35 IAC 620.410.e).3)) and the State of IL requirement for non-degradation (35 IAC 620.301.a)) (CA-5)

Revise the ODCM and/or program procedures as warranted to incorporate the State of PA requirements for radioactivity in groundwater. (CA-6)

Revise the ODCM and/or program procedures as warranted to incorporate the State of NJ requirements for radioactivity in groundwater (CA-7)

Clearly define to each station (extent of condition), the changes to the ODCM based on review of Illinois laws governing radioactive contamination of groundwater (potable water). Assign additional corrective actions to ensure site's ODCM reflects and implements applicable regulations. (CA-8)

Clearly define to each station (extent of condition), the changes to the ODCM based on review of Pennsylvania laws governing radioactive contamination of groundwater (potable water). Assign additional corrective actions to ensure site's ODCM reflects and implements applicable regulations. (CA-9)

Clearly define to each station (extent of condition), the changes to the ODCM based on review of New Jersey laws governing radioactive contamination of groundwater (potable water). Assign additional corrective actions to ensure site's ODCM reflects and implements applicable regulations. (CA-10)

Review the process by which the company becomes aware of new environmental laws and regulations for radiological and non-radiological issues and how they are integrated and communicated into company policies, programs, and procedures. Assign additional actions as necessary, if process changes are needed. (CA-14) 54 Page 9 of 11 Barrier Analysis Failed or ineffective barrier How Barrier Failed Why Barrier Failed Corrective action to Restore Barrier to Effectiveness Corporate Oversight Did not uncover 2 Corporate audits did not Revise CY-AA-170-000 and associated procedures to require audits of the CY-AA-170-000, missing State check program to ODCM against applicable laws and regulations at an acceptable frequency.

CY-AA-170-100, regulations or the sufficient detail Review the need for revision to include State regulations into Step 4.2.1 basis CY-AA-170-1000, state groundwater of the ODCM. Create additional actions as warranted. (CA-13) tritium concentration CY-AA-170-200, issue.

CY-AA-170-2000, CY-AA-170-2000, CY-AA-170-300, CY-AA-170-3100.

(FB-28)

Notification CF-6 NOS Audit NOSA-Did not uncover two NOS Audit Plan did not Discuss this RCR with the Corporate NOS Peer Group to evaluate changing BRW-05-08 (AR (2) missing state check program to the NOS auditing template standard for the ODCM Program. Document 2877 18) November 22, regulations or the sufficient detail, did not results and assign additional actions as required. (ACIT-28) 2005 state groundwater verify ODCM met (11-29) tritium concentration applicable state issue regulations Notice to other Site Did not always No procedure to assure Develop and implement Standard Exelon procedures to provide integrated Departments when an inform all affected consistent approach to and detailed spill and leak response requirements to ensure full compliance event occurred parties leaks/spills with state and federal laws and regulations and integrate Exelon resources to (FB-30) respond to radiological leaks and spills. (CAPR-4) 55 Page 10 of 11 Barrier Analysis Failed or ineffective barrier How Barrier Failed Why Barrier Failed Corrective action to Restore Barrier to Effectiveness Notice to sites of new Sites not informed of Program not robust Review the process by which the company becomes aware of new State Regulations new Illinois SB241, environmental laws and regulations for radiological and non-radiological (FB-31)

Community Right to issues and how they are integrated and communicated into company policies, Know programs, and procedures. Assign additional actions as necessary, if process changes are needed. (CA-14)

Work Orders Other Issue Model PM work orders Failed to have RP Did not know Title 35

- RP to provide information to Work Planning so that a work standard can be and current work sampling of leaks and IAC part 620 groundwater created for work activities that involve potentially tritiated water. This orders for B/D vacuum how to properly quality information will be used to update PM model work orders and current work breakers dispose of liquids not orders involving potentially triiiated water. (CA-25)

(FB-32) in work order

- Using the information provided by RP, create a work standard to be used for instructions.

work activities that involve potentially tritiated water and update PM model work orders and current work orders involving potentially tritiated water (RWP, sample for tritium, instructions for pumping tritiated water). (CA-27) 56 Page 11 of 11 Barrier Analysis Failed or ineffective barrier How Barrier Failed Why Barrier Failed Corrective action to Restore Barrier to Effectiveness Oversight CF-4 and CF-2 Weak management CF4: Braidwood Lack of questioning OP-AA-106-101-1002, Exelon Nuclear Issues Management, will be revised review and oversight of Senior Management attitude regarding to: 1) improve Corrective Action Program (CAP) controls of Issues spill response did not question the unplanned spills from the Management teams, 2) utilize the tools and techniques of the Exelon HU-AA-activities.

radiological impact of blowdown system.

102 and HU-AA-1212, Technical Human Performance Practices and (FB-33) all leaks that had Technical Task Risk/Rigor Assessment, Pre-Job Brief, Independent Third happened.

Party Review, and Post-Job Brief procedures, 3) strengthen reporting requirements to affected station Senior Management, and 4) define affected station Senior Management responsibilities for "cradle to grave" oversight and challenge of events and issues. (CAPR 5)

CF2: Lack of Did not know Title 35 The Braidwood Tritium Remediation Team will determine the methodology questioning attitude IAC part 620 groundwater and implement the plan for future radiological releases, including leakage for low level Tritium concentration standards. (CAPR 2) radiological spills.

limits Develop a case study of this event. Provide initial and continuing training for The need for a near MRC/SOC members. (CA-2) zero leakage standard was not identified.

Evaluate conducting Dynamic Learning Activity (DLA) on a Duty Team basis using 2000 release conditions and revised response and reporting procedures implemented in CAPR 4. Create additional assignments as warranted. (CA-3)

Review other potential leaks beyond tritium to address extent of condition regarding Exelon management's control of hazardous material spills. If deficiencies are noted, write IR's to have those deficiencies addressed.

(CA-4) 57 A

-Cause & Effect Analysis Effect Symptom Why Cause / Reason Vacuum breaker leaks Small 'leaks were never considered to occurred after 2000 be a problem Small leaks were never 2000 Root Cause Team only considered.to be a problem addressed major failures 2000 Root Cause Team 2000only adr sed TemajThe 2000 charter was to determine the only addressed major major failures failures The charter was narrowly scoped due The 2000 charter was to to two teams were developed to determine the major failures perform the Root Cause and Radiological spill Response The charter was narrowly scoped due to two teams Was not considered a problem as were developed to perform small leaks did not leave the site the Root Cause and Radiological spill Response 58

Was not considered a problem as small leaks did People did not know the 1991 statute not leave the site for groundwater.

The need for a near zero leakage 1991le statte for standard was not identified, due to a gr d watutefor.

lack of Technical Rigor/Questioning groundwater.

÷Attitude (Root Cause 2).

The need for a near zero leakage standard was not identified, due to a lack of At this time the HU-AA-1212 and 102 Technical Rigor/

procedures did not exist.(CAPR 3)

Questioning Attitude (Root Cause 2).

59 B

-Cause & Effect Analysis Effect I Symptom Why Cause / Reason Tritium found off site Inadequate response Personnel not aware of the B/D water Tritium exceeding groundwater Inadequate response limits. Belief that release package authorized unrestricted release to environment.

Personnel not aware of the B/D water Tritium Personnel not aware of the IEPA exceeding limits. Belief that tritium limit requirements for release package authorized groundwater unrestricted release to environment.

Personnel not aware of the JEPA tritium limit Knowledge deficiency requirements for groundwater No integrated procedural guidance for Knowledge deficiency groundwater radiological spills (Root Cause 3) 60 C

-Cause & Effect Analysis Effect I Symptom Why Cause / Reason Tritium found off site Ineffective response in 2000 Ineffective response in Sampling not performed for tritium in 2000 groundwater Sampling not performed for Poor decision by Spill Team not to tritium in groundwater sample Poor decision by Spill Weak questioning attitude and Team not to sample inadequate challenge culture (Root Cause 4)

OP-AA-106-101-1002 (currently, OP-Weak questioning attitude AA-101-503 in year 2000) was not and inadequate challenge specific enough in regarding culture management reporting requirements

_(CAPR 5) 61 E&CF Chart

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on.t.j fks&*U 64 Change Analysis (The Change Analysis tool was inadequate to use effectively and was therefore not utilized as an input to this root cause report.)

Factors That Interview Successful Failed Change?

Causal Influence Questions Performance Performance Factor?

Performance Factors That Influence Interview Successful Failed Change?

Causal Performance Questions Performance Performance Factor?

Factors That Interview Successful Failed Change?

Causal Influence Questions Performance Performance Factor?

Performance 65 Page 1 of 6 Circ Water Blowdown System BACKGROUND INFORMATION The primary function of the Circulating Water Blowdown System is to provide for lake turnover to prevent undesirable chemical buildup in the lake. The secondary function of the Circ Water Blowdown System is to provide dilution for liquid rad waste releases. (See Attachment 7 for map.)

The Circulating Water Blowdown System is designed to return Cooling Lake water back to the Kankakee River. Processed fluids from the Sewage Treatment System and the Radwaste Treatment Systems discharge directly into the Circulating Water Blowdown system, where dilution occurs prior to release to the Kankakee River.

The Wastewater Treatment Plant and the De'mineralizer Regenerant Waste systems along with various strainer/filter backwashes are returned to the Cooling Lake and thus are indirectly returned to the Kankakee River through the Blowdown line after dilution by the Cooling Lake.

The Circ Water Blowdown system begins at the Circ Water System supply piping to the condenser. Two 24" carbon steel pipes tap off the Circulating Water supply piping (one from each unit) and combine into-a 36" common header. A motor operated isolation valve (1/2CW018) is provided on each 24" line.

The 6" Radwaste Treatment System discharge pipe connects to the 36" blowdown header.

Downstream of the radwaste connection, the blowdown pipe is expanded to 48" prior to connection to the 3" Sewage Treatment Plant discharge pipe.

The 48" diameter blowdown pipe is reinforced concrete pipe (RCP) and runs along owner-controlled property until reaching the Blowdown structure at the Kankakee River.

Eleven vacuum breaker assemblies are incorporated at the high points along the 48" diameter RCP to prevent pipe implosion when the blowdown system is shut off.

The 48" RCP is split and reduced to two 24" discharge pipes at the Kankakee River blowdown structure. Each 24" discharge pipe was originally equipped with a motor operated spray valve. The entire piping network is approximately 29,000 ft long and was originally operated at about 12,000 gpm (-2.5 ft/s).

The Circ Water Blowdown system was originally designed to be maintained full of water and pressurized. This was accomplished through manipulation of the Blowdown Spray Valves, at the Kankakee River blowdown structure. These valves were susceptible to freezing due to their location and system operation requirements. Based on this, other maintenance issues, and parts obsolescence, these valves were eventually abandoned in the full open position in the late 66 Page 2 of 6 1980's-. To allow-air release from the piping on start-up and to allow air introduction to protect against vacuum damage to the piping, vacuum breakers are installed.

'VA EMA9 0j"

  • N i.9 I

NOTE: Above is typical. Braidwood has 48" reinforced concrete pipe. Other differences may apply.

System control was transferred to the upstream motor operator isolation valves located in the turbine building. This modification caused the blowdown line to operate in a partially voided condition in various locations, depending on elevation which allowed column separation water hammer events to occur when flow rates were changed significantly, i.e.; during system start-up or shut down.

Events were not initially seen because blowdown was essentially in service all the time. As a result of this change in operational methodology, the blowdown system would no longer be maintained full and pressurized upon shutdown.

Minimal technical review was performed on the hydraulic transient effects on the vacuum breakers from this method of operation.

67 Page 3 of 6 A more rigorous technical review may have initiated the installation of surge protected check valves (which eventually occurred in 2001) before the majority of the leaks described in this report occurred. This is a missed opportunity.

In 1997, the Chemical Feed System was relocated from the Turbine Building to the Lake Screen House under modification M20-0-95-003. One of the primary reasons for centralization of the Chemical Feed system to the Lake Screen House was to reduce maintenance cost.

This design change necessitated isolating the Circ Water Blowdown System on a daily basis to accommodate biocide injections into the Circ Water System, because our permits do not authorize discharge of biocide to the Kankakee River. When both units were in operation this was not an issue because partial blowdown flow was maintained from the unit not being chlorinated. The problem became apparent during outages when one unit was shut down. In this configuration, blowdown flow was stopped and started whenever the operating unit was chlorinated.

The daily requirement to isolate Circulating Water Blowdown for biocide injection, prompted the Operations Department to challenge the BwOP CW-12 procedural requirement to slowly open the motor operated valves for system start-up.

BwOP CW-12 was revised to allow fast motorized operation of motor operated valves, in lieu of slower manual throttling following short periods of system shutdown (i.e.: biocide injections).

68 Page 4 of 6 Typical vacuum breaker:

AI R. RE LEASE VALVIE Ah%11 B lITTERLY VALVE 10 IFVI0 h4AL-CSIEE C"P34AW.V~

EWW)V:

~*~Efl.ata I.S.O MI.SScMJCWSC.,r Work history on the Circulating Water Blowdown System vacuum breakers was reviewed. There were no recorded vacuum breaker float assembly failures prior to 2000, however several instances of leaking air release valves were noted from the review. The VB-3 air release valve was discovered leaking in 12/98. PIF #

A1998-04324 was generated to address the flooding of site property and the Smiley Road ditch immediately adjacent to site property. The piping to the air release valve on the VB-1 failed in 12/96.

The complete vacuum breaker assembly including air release valve was replaced with a new assembly in 1997.

It should be noted that the VB-1 vacuum breaker failed again on 11/20/2000. The float assembly broke at the bowl to guide bar weld.

No other significant work history was identified.

The failure of the VB-2 float assembly was discussed with the vendor. Based on the failure description, the vendor indicated that it appeared to be consistent with the effects of a pressure surge (i.e. water hammer). The vendor indicated that surge protection check valves should be considered for a vacuum breaker when pipe flows exceed 6 ft/s and are required when flow velocities exceed 10 ft/s.

The vendor also recommended a 7-10 year PM frequency to address valve elastomer degradation. The condition was addressed by revising the operating procedure BwOP CW-12 to manually open and close the valves to slowly initiate or terminate blowdown flow.

69 Page 5 of 6 The present circulating water blowdown system operates as follows. On system startup, the air/vacuum valve exhausts large amounts of air from the piping system until the float assembly in the air/vacuum valve rises with water level to close and seal during normal system operation.. To prevent the inrushing water from causing damage to the air/vacuum valve float, a surge check valve is installed just underneath the air/vacuum valve. The surge check is a spring loaded, normally open valve, which passes air through unrestricted. When water rushes into the check valve, the disc begins to close against the spring tension and reduces the flow rate of water into the air/vacuum valve by means of throttling holes in the disc. This ensures gentle closing of the air/vacuum valve float, regardless of initial flow velocity into the valve and minimizes pressure surges. Upon system shutdown, the vacuum valve is designed to open as water level decreases.

The air release valve provides two functions. The primary function is to release small amounts of entrained air that accumulates at the high points during normal system operation. If not removed, this air that would increase head loss and reduce process flow. The air release valve also facilitates earlier opening of the main air/vacuum valve on system shutdown. On shutdowns, air pockets that develop at high points may be at positive pressure, tending to hold the main air/vacuum float on its seat even though water level is below the float assembly. However, the air release valve will vent the air and allow the main air/vacuum valve to open as soon as water level drops. Each vacuum breaker is provided with a butterfly isolation valve to facilitate vacuum breaker maintenance.

Modification of 2001-2003 changed the design of the air / vacuum valve assembly to a slow closing design with the use of a surge protector valve in-line.

This modification protects the air/vacuum valves from pressure surges experienced during water hammer events.

Modification of 2003 installed CW Blowdown Booster Pumps to increase the blowdown flow rate to 25,000 gpm for improving lake chemistry. With increased flow rates during booster pump operation the volume of voided blowdown line may decrease, closing previously open air / vacuum valves under lower flow conditions. Start up and shut down procedures for the booster pumps specify flow / pump increase / decrease ramp rates to minimize potential column separation water hammer pressure surges.

70 Page 6 of 6 Modification of 2005 installed a de-chlorination modification to allow continuous operation of the Blowdown System while performing unit chlorination. This modification allowed blowdown to be in-service essentially all the time, reducing the potential for air / vacuum valves leaks caused by system flow rate changes.

The aggregate impact of the three modifications was to assure nearly continuous operation of the blowdown system which minimizes the inclusion of air and the possibility of damaging water hammer at the vacuum breaker valves.

71

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NTnrth Godley Illinois Braidwood Station Kankakee River 75 Review of Exelon Hazmat Spill Response Procedures Page 1 of 3 In general, there is no spill response procedure, which would acknowledge the subsurface water transport mechanism from onsite to offsite locations. The three documents reviewed were a draft procedure circulated in 10/16/90, "General Action Plan for Response to Unmonitored Releases and Very Low Level Radioactive Spills", BwAP 750-4, "Hazardous Material Spill Response", and BwAP 1100-16, "Fire/Hazardous Materials Spill and/or Injury Response", and NSP-RP-6101, "10 CFR 50.75(g)(1) Documentation Requirements".

The most significant barrier deficiencies noted was that the 1990 draft procedure may have prompted reviewing hydrology and dose to the public from radiological contamination of groundwater.

Additionally, the procedure to document the spill for 10 CFR 50.75(g)(1) requirements for decommissioning prompts to perform a potential dose impact to the public from the spill, but does not require any specific pathway (i.e. subsurface migration of contaminants to drinking water).

Procedure Relevant Content Barrier Analysis Draft Procedure CSG-001, The draft procedure contained pertinent information about:

Missed opportunity to "General Action Plan for For situations involving subsurface contamination, erect a barrier.

Response to Unmonitored corrective action may mean the preparation of a Releases and Very Low Level submittal pursuant to the I1 Adm. Code 340.3020 and 10 This procedure may have Radioactive Spills" CFR 20.302 requesting the in-place disposal of prompted recognition of subsurface contamination, dose impacts from the Circulated as a Draft Environment - refers to any surface water, groundwater, contamination of procedure 10/16/90. No sanitary or storm sewers, soil, land surface, or subsurface groundwater and record of this becoming an strata and vegetation, supporting hydrology actual procedure.

Subsurface contamination and hydrology 'concerns issues.

0 Reviewing to ensure the spill is not in excess of This procedure contains Reportable Quantity quantities in 40 CFR 302 App B or May have provided an information relevant to the 40 CFR 355 App A opportunity for all former underground water dose 0

Required evaluation of exposure pathways from CornEd nuclear plants to pathway to the public now infiltration and contamination of groundwater.

recognize the potential being evaluated. Not issue.

implementing this procedure was a missed opportunity to erect a barrier to recognize Page 2 of 3 BwAP 750-4, "Hazardous In general, site personnel would not consider entry into the Minor missed barrier.

Material Spill Response" hazmat spill procedure for a water spill.

The procedure contains the following pertinent information:

Missing this barrier was The procedure references Hazardous Materials as listed in of no consequence. The 40 CFR 302.4, which lists many chemicals, but not RP organization did not 76

Procedure Relevant Content Barrier Analysis radioactive material. The intent of this reference is to have subsequent ensure that a "Reportable Quantity" has not been spilled proceduresto respond to on the ground. The absence of radioactive materials the subsurface transport from the list in the procedure does not preclude someone issues, which are of issue from looking for radioactive material in 40 CFR 302.4, today.

but the procedure does not offer a clear barrier to trip recognition of a radioactive material spill as a hazmat event per this procedure. Even if radioactive materials was clearly on the Reportable Quantity list, the RP organization does not have a procedure documenting additional required actions.

The procedure states, "Spills containing radiologically contaminated material shall be reported to the Radiation Protection Dept.

BwAP 1100-16, The hazmat procedure does not contain information to specify Minor missed barrier.

"Fire/Hazardous Materials actions that might direct specific radiological actions to minimize Spill and/or Injury Response" the significance of a similar event. The procedure essentially Missing this barrier was defers radiological spills to the RP organization. The procedure of no consequence. The contains the following radiological information:

RP organization did not Notify Rad Protection to dispatch personnel to the have subsequent fire/spill area for radiation detection and first aid procedures to respond to purposes.

the subsurface transport issues, which are of issue today.

Page 3 of 3 NSP-RP-6 101, "10 CFR 50.75(g)(1) Documentation Requirements" This procedure is intended to provide the following information as required from the regulation:

10 CFR 50.75(g)(1) Records of spills or other unusual occurrences involving the spread of contamination in and around the facility, equipment, or site. These records may be limited to instances when significant contamination remains after any cleanup procedures or when there is reasonable likelihood that contaminants may have spread to inaccessible areas as in the case of possible seepage into porous materials such as concrete.

These records must include any known information on identification of involved nuclides, quantities, forms, and concentrations.

The actual procedure requires addressing:

o Concentrations of involved radionuclides o

Quantities of material(s) o Forms of material(s), (e.g. solubility and permeability of the contaminant) o Description of the event o

Impact of the remaining radioactive material on the health and safety of the public o

Affected areas The procedure prompts to perform a potential dose impact to members of the public, but it does not describe pathways to be analyzed (i.e. subsurface migration of contaminants to drinking water). The general absence of tools to calculate the specifics of subsurface transport mechanisms may have prompted actual measurements through the drilling of wells to sample water or sample existing offsite wells. Corrective Action (CA-2 1) addresses performing a dose assessment to determine the dose impact to the public from radiological spills by including this action in the 10 CFR 50.75(g)(1) procedure. The purpose of corrective action 21 is to link Missed barrier The procedure requires an assessment of potential dose to the public from the remaining radioactive material, but does not prompt for the pathway of subsurface migration through groundwater to drinking water.

77

Procedure Relevant Content Barrier Analysis the 10CFR 50.75(g) with the ODCM for tracking the impact on dose of isotopics in groundwater.

78 Reportability Manual Review - LS-AA-1 020 and LS-AA-1 110 Page 1 of 3 Various documents were reviewed by this Root Cause Investigation Team to determine the expected reporting requirements for an event such as discovering radiologically contaminated water leaking from a plant system onto the ground within the owner-controlled area.

LS-AA-1020 Radiological Decision Tree was reviewed. The Liquid Release or Spill portion of the tree references SAF 1.9, News Release or Notification of Other Government Agency. SAF 1.9 requires NRC notification for any event related to the health and safety of the public or onsite personnel, or protection of the environment requiring a news release or notification of another government agency. One example described is the unplanned release of radioactively contaminated materials. Since the vacuum breaker leaks (spills) were contained onsite, the leak would not be characterized as a release per the Offsite Dose Calculation Manual.

Since the leak was onsite, there was no perceived health or safety risk to the public. A review of several Incident Reports (IR's) indicates that these leaks were not considered a public risk since the leaks were onsite. These IR's also reasonably concluded that National Pollution Discharge Elimination System (NPDES) violations did not occur and therefore, Environmental Protection Agency (EPA) notification was not required. Based on the nature of the leak, there was no safety or health risk to onsite personnel. Therefore, it was reasonable to conclude that these events were not reportable per SAF 1.9.

The Liquid Release or Spill portion of the Radiological Decision Tree also references RAD 1.1, Events Involving Byproduct, Source or Special Nuclear Material that Cause or Threaten to Cause Significant Exposure or Release.

One of the reporting requirements concerns the release of radioactive material inside or outside the restricted area, but is not reportable if the location is not normally stationed during routine operations. Since personnel would not normally be stationed at the vacuum breakers, reporting was not required.

RAD 1.4, Liquid Effluent Release requires reporting when radioactive material is present at levels greater than 10 times applicable limits. The piping leaks were within the restricted areas and therefore were not considered an effluent release. Migration of contaminated groundwater offsite should be considered an effluent release, but was not considered. To date, measurable tritium concentrations in groundwater offsite are within 10 times the applicable limits. The event is not reportable per RAD 1.4.

RAD 1.8, Effluent Release was not considered applicable since a release normally occurs at the authorized or intended discharge point.

Therefore, reportability per RAD 1.8 was not considered.

Offsite release via groundwater was not considered.

Based on the measured tritium results off site, the requirements described in RAD.1.8 have not been exceeded and therefore, reportability per RAD 1.8 is not required.

79 Reportability Manual Review - LS-AA-1 020 and LS-AA-1110 Page 2 of 3 RAD 1.21, Release of Radionuclides, requires reporting when the limits of 40 CFR 302 are-exceeded. For tritium, the 40 CFR 302 limit is 100 Curies released within a 24-hour period.

Review of effluent release data indicates that the 100-curie limit was not challenged during radioactive releases over the vacuum breaker leakage timeframe. Therefore, reportability per RAD 1.21 was not required.

RAD 1.22, Release of Hazardous Substances-(including radionuclides) is not applicable based on the RAD 1.21 discussion.

The other sections of the Liquid Release or Spill portion of the Radiological Decision Tree do not apply.

The other sections of the Radiological Decision Tree were reviewed and do not apply.

LS-AA-1020 Environmental decision tree was also reviewed.

The Other Significant Event section was reviewed. ENV 3.26 Unusual or Important Environmental Events requires reporting of any event that did or could have significant environmental impact. It is reasonable that a blowdown water spill onsite would not have a significant environmental impact and therefore notification would not be made. However, potential groundwater contamination and migration to public wells was not considered.

The other sections of the Environmental Decision Tree were reviewed and would not apply.

40 CFR 141.16 states that the average annual tritium concentration shall not exceed 20,000 pCi/L in a community drinking water system. A community drinking water system is defined in the regulation as a public water system that serves at least 15 year round residents. The reportability manual appropriately references 40 CFR 141.

35 IAC 620 has the same 20,000 pCi/L limit and definition of community drinking water system as described in 40 CFR 141.16. However, 35 IAC 620 does not limit the tritium concentration to community drinking water. This Illinois standard limits tritium concentration in "Class I: Potable Resource Water," which is defined, in part, as water located 10 feet or more below the surface that is capable of potable use. Per discussion with Conestoga-Rovers & Associates and the Exelon Hydrologist, onsite groundwater at Braidwood station is classified as Class I: Potable Resource Water in accordance with 35 IAC 620.

Therefore, any tritium leakage into the groundwater onsite could exceed the requirements of 35 IAC 620.

The reporting requirements for the Radiological Environmental Monitoring Program (REMP) are specified in the Braidwood ODCM, section 12.5.1. Table 12.5-2 lists REMP reporting levels for tritium and other radionuclides that are monitored in various types of samples obtained. These ODCM required reporting requirements are not listed in the Reportability Manual. Groundwater samples indicate that the reporting level of tritium per Table 12.5-2 have been exceeded.

80 Reportability Manual Review-LS-AA-1020 and LS-AA-1110 Page 3 of 3 The Braidwood ODCM REMP drinking water tritium concentration reporting requirements are consistent with the requirements of 40 CFR 141 and 35 IAC 620. However, per ODCM Section 12.5.1, reportability is based on a quarterly average. 40 CFR 141 and 35 IAC 620 reportability are based on an annual average - the ODCM reportability is conservative and consistent with the recommendations in NUREG 1301 Section 3.12.1.

There is no mention of 35 IAC 611 or 35 IAC 620 requirements in the Braidwood ODCM (CA4).

The Reportability Manual was reviewed for references to the various drinking water and groundwater standards.

There is appropriate reference to 40 CFR 141 and 35 IAC 611.

However, there were not sufficient references to 35 IAC 620. Based on this review, there was inadequate knowledge of the requirements of 35 IAC 620 and the transport of radioactivity offsite via the groundwater pathway.

In 2005, Illinois passed SB241, which became effective on July 25, 2005. This legislation states that if the Illinois Environmental Protection Agency (IEPA) makes a determination that groundwater poses a threat of exposure above Class I groundwater standards (35 IAC 620),

then public notification is required.

The IEPA does not require conclusive evidence of exceeding a standard. The notification can be based on modeling that demonstrates a trend towards exceeding a standard.

While this legislation does not require site reporting and does not change daily operation, it does impact the site because public notification can be made based on groundwater contaminant concentrations that are below reportable thresholds. There is no mechanism in place for site technical expertise to be made aware of new legislation such as Illinois SB241 (CA8).

References Braidwood Offsite Dose Calculation Manual LS-AA-1020, Reportability Reference Manual, Revision 8 LS-AA-1 110, Reportable Event SAF, Revision 6 LS-AA-1 120, Reportable Event Radiation (RAD), Revision 3 LS-MW-1 310, Reportable Event SAF, Revision 3 LS-MW-1 340, Reportable Event, ENV, Revision 4 LS-AA-1400, Event Reporting Guidelines, Revision 2 LS-MW-1340, Reportable Events, ENV, Revision 4 40 CFR 302, Designation, Reportable Quantities, and Notification 40 CFR 141, National Primary Drinking Water Regulations 35 IAC 611, Primary Drinking Water Standards 35 IAC 620, Groundwater Quality 81 0

Page 1 of 14 Summary of Applicable State, Federal, and Offsite Dose Calculation Manual (ODCM) Regulations and Requirements for Tritium Releases to the Environment TITLE 35: ENVIRONMENTAL PROTECTION SUBTITLE F: PUBLIC WATER SUPPLIES CHAPTER I: POLLUTION CONTROL BOARD PART 620.410 GROUNDWATER QUALITY Effective November 25, 1991Class I: Potable Groundwater e) Beta Particle and Photon Radioactivity

1) Except due to natural causes, the average annual concentration of beta particle and photon radioactivity from man-made radionuclides shall not exceed a dose equivalent to the total body organ greater than 4 norem/year in Class I groundwater. If two or more radionuclides are present, the sum of their dose equivalent to the total body, or to any internal organ shall not exceed 4 mrem/year in Class I groundwater except due to natural causes.
2) Except for the radionuclides listed in subsection (e)(3), the concentration of man-made radionuclides causing 4 mrem total body or organ dose equivalent must be calculated on the basis of a 2 liter per day drinking water intake using the 168-hour data in accordance with the procedure set forth in NCRP Report Number 22, incorporated by reference in Section 620.125(a).
3) Except due to natural causes, the average annual concentration assumed to produce a total body or organ dose of 4 mrem/year of the following chemical constituents shall not be exceeded in Class I groundwater:

Critical Standard Constituent Organ (pCi/L)

Tritium Total body 20,000.0 Strontium-90 Bone marrow 8.0 82 0

Page 2 of 14 ODCM Appendix A Revision 3 January 2002 A.2.2 Liquid Effluent Concentrations Requirement Requirement One method of demonstrating compliance to the requirements of 10 CFR 20.1301 is to demonstrate that the annual average concentrations of radioactive material released in gaseous and liquid effluents do not exceed the values specified in 10 CFR 20 Appendix B, Table 2, Column 2. (See 10 CFR 20.1302(b)(2).)

However, as noted in Section A.5.1, this mode of 10 CFR 20.1301 compliance has not been elected.

[Mode of compliance selected is as follows:]

As a means of assuring that annual concentration limits will not be exceeded, and as a matter of policy assuring that doses by the liquid pathway will be ALARA; RETS provides the following restriction:

"The concentration of radioactive material released in liquid effluents to unrestricted areas shall be limited to ten times the concentration values in Appendix B, Table 2, Column 2 to 10 CFR 20.1001-20.2402."

This also meets the requirement of Station Technical Specifications and RETS.

A.2.4 Tank Overflow Requirement To limit the consequences of tank overflow, the RETS/Technical Specifications may limit the quantity of radioactivity that may be stored in unprotected outdoor tanks. Unprotected tanks are tanks that are not surrounded by liners, dikes, or walls capable of holding the tank contents and that do not have tank overflows and surrounding area drains connected to the liquid radwaste treatment system. The specific objective is to provide assurance that in the event of an uncontrolled release of a tank's contents, the resulting radioactivity concentrations beyond the unrestricted area boundary, at the nearest potable water supply and at the nearest surface water supply, will be less than the limits of 10 CFR 20 Appendix B, Table 2; Column 2.

The Technical Specifications and RETS may contain a somewhat similar provision. For most nuclear power stations, specific numerical limits are specified on the number of curies allowed in affected tanks.

83 0

Page 3 of 14 A.2.5 Operability and Use of the Liquid Radwaste Treatment System Requirement The design objectives of 10 CFR 50, Appendix I and RETS/Technical Specifications require that the liquid radwaste treatment system be operable and that appropriate portions be used to reduce releases of radioactivity when projected doses due to the liquid effluent from each reactor unit to restricted area boundaries exceed either of the following (see Section 12.3 of each station's RETS or Technical Specifications);

  • 0.06 mrem to the total body in a 31 day period.
  • 0.2 mrem to any organ in a 31 day period.

A.2.6 Drinking Water Five nuclear power stations (Braidwood, Dresden, LaSalle, Quad Cities, and Zion) have requirements for calculation of drinking water dose that are related to 40 CFR 141, the Environmental Protection Agency National Primary Drinking Water Regulations. These are discussed in Section A.6.

A.6 DOSE DUE TO DRINKING WATER (40 CFR 141)

The National Primary Drinking Water Regulations, 40 CFR 141, contain the requirements of the Environmental Protection Agency applicable to public water systems. Included are limits on radioactivity concentration. Although these regulations are directed at the owners and operators of public water systems, several stations have requirements in their Technical Specifications related to 40 CFR 141.

A.6.1 40 CFR 141 Restrictions on Manmade Radionuclides Section 141.16 states the following (not verbatim):

(a)

The average annual concentration of beta particle and photon radioactivity from man-made radionuclides in drinking water shall not produce an annual dose equivalent to the total body or any internal organ greater than 4 millirem/year.

(b)

Except for the radionuclides listed in Table A-0, the concentration of man-made radionuclides causing 4 mrem total body or organ dose equivalents shall be calculated on the basis of drinking 2 liter of water per day. (Using the 168 hour0.00194 days <br />0.0467 hours <br />2.777778e-4 weeks <br />6.3924e-5 months <br /> data listed in "Maximum Permissible Body Burdens and Maximum Permissible Concentration of Radionuclides in Air or Water for Occupational Exposure, "NBS Handbook 69 as amended August 1963, U.S. Department of Commerce.). If two or more radionuclides are present, the sum of their annual dose equivalents to the total body or any organ shall not exceed 4 milliremlyear.

84 0

Page 4 of 14 TABLE A-0 AVERAGE ANNUAL CONCENTRATIONS ASSUMED TO PRODUCE A TOTAL BODY OR ORGAN DOSE OF 4 MREM/YR Radionuclide Critical Organ pCi / liter Tritium Total body 20,000 Strontium-90 Bone marrow 8

LIQUID EFFLUENTS Chapter 12 Revision 7 September, 2002 12.3.1 Concentration Operability Requirements 12.3.1.A The concentration of radioactive material released in liquid effluents to UNRESTRICTED AREAS (see Braidwood Station ODCM Annex, Appendix F, Figure F-i) shall be limited to 10 times the concentration values in Appendix B, Table 2, Column 2 to 10 CFR 20.1001-20.2402, for radionuclides other than dissolved or entrained noble gases. For dissolved or entrained noble gases, the concentration shall be limited to 2x10-4 microCurie/mI total activity.

Applicability: At all times Action:

1t With the concentration of radioactive material released in liquid effluents to UNRESTRICTED AREAS exceeding the above limits, immediately restore the concentration to within the above limits.

Surveillance Requirements 12.3.1.B.1 Radioactive liquid wastes shall be sampled and analyzed according to the sampling and analysis program of Table 12.3-1.

12.3.1.B.2 The results of the radioactivity analysis shall be used in accordance with the methodology and parameters in the ODCM to assure that the concentrations at the point of release are maintained within the limits of 12.3.1.A.

85 0

Page 5 of 14 Bases 12.3.1.C This section is provided to ensure that the-concentration of radioactive materials released in liquid waste effluents to UNRESTRICTED AREAS will be less than 10 times the concentration values in Appendix B, Table 2, Column 2 to 10 CFR 20.1001-20.2402. This limitation provides additional assurance that the levels of radioactive materials in bodies of water in UNRESTRICTED AREAS will result in exposures within: (1) the Section II.A design objectives of Appendix 1, 10 CFR 50, to a MEMBER OF THE PUBLIC, and (2) the limits of 10 CFR 20.1301.

This section applies to the release of radioactive materials in liquid effluents from all units at the site.

The required detection capabilities for radioactive materials in liquid waste samples are tabulated in terms of the lower limits of detection (LLDs). Detailed discussion of the LLD, and other detection limits can be found in HASL Procedures Manual, HASL-300 (revised annually), Currie, L.A., "Limits for Qualitative Detection and Quantitative Determination -

Application to Radiochemistry," Anal. Chem. 40, 586-93 (1968), and Hartwell, J.K.,

"Detection Limits for Radioana!ytical Counting Techniques," Atlantic Richfield Hanford Company Report ARH-SA-21 5 (June 1975).

86 0

Page 6 of 14 TABLE 12.3-1 RADIOACTIVE LIQUID WASTE SAMPLING AND ANALYSIS PROGRAM LIQUID RELEASE SAMPLING MINIMUM ANALYSIS TYPE OF ACTIVITY LOWER, LIMIT OF TYPE FREQUENCY FREQUENCY ANALYSIS DETECTION (LLD)(')

(PiCVmI)

I.

Batch Release P

P Principal Gamma Emitters(7) 5x10-7 Tanks(2)

Each Batch Each Batch 1-131 1 xi 0.6 P

M Dissolved and Entrained 1x10"5 One Batch/M Gases (Gamma Emitters)

P M

H-3 1 xi 05 Each Batch Composite (3)

Gross Alpha 1 x1 0-7 P

Q Sr-89, Sr-90 5x1 0-8 Each Batch Composite (3)

Fe-55 lxi 06

2.

Continuous W

Principal Gamma Emitters(7) 5x1 0 7 Releases (4)

Continuous(s)

Composite(5) 1-131 1x10s6

a.

Circulating Water M

M Dissolved and Entrained lx105 Blowdown Grab Sample Gases (Gamma Emitters)

b.

Waste Water M

H-3 1x10*5 Treatment Continuous(5)

Coin posite(5 )

Discharge to Circulating Water Discharge Gross Alpha 1 x1 07

c.

Condensate Continuous(5 )

Q Sr-89, Sr-90 5x1 0.8 Polisher Sump Composite(5 )

Discharge Fe-55 1x10 6 87 0

Page 7 of 14 TABLE 12.3-1 (Continued)

RADIOACTIVE LIQUID WASTE SAMPLING AND ANALYSIS PROGRAM LIQUID RELEASE SAMPLING MINIMUM ANALYSIS TYPE OF ACTIVITY LOWER LIMIT OF TYPE FREQUENCY FREQUENCY ANALYSIS DETECTION (LLD)(1)(PCi/mI)

3. Continuous W(6)

W(6)

Principal Gamma 5x10-7 Release(4)

Grab Emitters(7)

Essential Sample Service Water Reactor Containment Fan Cooler (RCFC) Outlet Line 1-131 x10"6 H-3 lx10-5 M (6)

Dissolved and 1x10.5 Entrained Gases (Gamma Emitters)

4. Continuous None None Principal Gamma 5x10-7 Surge Tank Emitters(7)

Vent-Component Cooling Water Line (8)

Dissolved and I xl0 5 Entrained Gases (Gamma Emitters) 1-131 1xl 0-6 88 0

Page 8 of 14 TABLE 12.3-1 (Continued)

RADIOACTIVE LIQUID WASTE SAMPLING AND ANALYSIS PROGRAM TABLE NOTATIONS (1)

The LLD is defined, for purposes of these sections, as the smallest concentration of radioactive material in a sample that will yield a net count, above system background, that will be detected with 95% probability with only 5% probability of falsely concluding that a blank observation represents a "real" signal.

For a particular measurement system, which may include radiochemical separations:

LLD =

4.66sh E x V x 2.22 x10 6 x Y x exp (-XAt)

Where:

LLD = the lower limit of detection (microCuries per unit mass or volume),

Sb = the standard deviation of the background counting rate or of the counting rate of a blank sample as appropriate (counts per minute),

E = the counting efficiency (counts per disintegration),

V = the sample size (units of mass or volume),

6 2.22 X1i0 = the number of disintegrations per minute per microCurie, Y = the fractional radiochemical yield, when applicable, k = the radioactive decay constant for the particular radionuclide (sec.), and At = the elapsed time between the midpoint of sample collection and the time of counting (sec).

Typical values of E, V, Y, and At should be used in the calculation.

Alternative LLD Methodology An alternative methodology for LLD determination follows and is similar to the above LLD equation:

LLD = (2.71 + 4.654/B) x Decay E x q x b x Y x t (2.22 X10 6) 89 0

Page 9 of 14 TABLE 12.3-1 (Continued)

RADIOACTIVE LIQUID WASTE SAMPLING AND ANALYSIS PROGRAM TABLE NOTATIONS Where:

B = background sum (counts)

E = counting efficiency, (counts detected/disintegration's) q = sample quantity, (mass or volume) b = abundance, (if applicable)

Y = fractional radiochemical yield or collection efficiency, (if applicable) t = count time (minutes) 2.22X106 = number of disintegration's per minute per microCurie 2.71 + 4.65B= k2 + (2k q/2 q B), and k = 1.645.

(k=value of the t statistic from the single-tailed t distribution at a significance level of 0.95 and infinite degrees of freedom. This means that the LLD result represents a 95% detection probability with a 5% probability of falsely concluding that the nuclide present when it is not or that the nuclide is not present when it is.)

Decay = eýt [XRT/(1 -eXRm)] [XT,(1 -e'Td)], (if applicable)

X = radioactive decay constant, (units consistent with At, RT and Td)

At = "delta t', or the elapsed time between sample collection or the midpoint of sample collection and the time the count is started, depending on the type of sample, (units consistent with X)

RT= elapsed real time, or the duration of the sample count, (units consistent with k)

Td = sample deposition time, or the duration of analyte collection onto the sample media',

(units consistent with X)

The LLD may be determined using installed radioanalytical software, if available. In addition to determining the correct number of channels over which to total the background sum, utilizing the software's ability to perform decay corrections (i.e. during sample collection, from sample collection to start of analysis and during counting), this alternate method will result in a more accurate determination of the LLD.

90 0

Page 10 of 14 It should be recognized that the LLD is defined as a before the fact limit representing the capability of a measurement system and not as an after the fact limit for a particular measurement.

TABLE 12.3-1 (Continued)

RADIOACTIVE LIQUID WASTE SAMPLING AND ANALYSIS PROGRAM TABLE NOTATIONS (2)

A batch release is the discharge of liquid wastes of a discrete volume. Prior to sampling for analyses, each batch shall be isolated, and then thoroughly mixed to assure representative sampling.

(3)

A composite sample is one in which the quantity of liquid sampled is proportional to the quantity of liquid waste discharged and in which the method of sampling employed results in a specimen that is representative of the liquids released.

(4)

A continuous release is the discharge of liquid wastes of a nondiscrete volume, e.g., from a volume of a system that has an input flow during the continuous release.

(5)

To be representative of the quantities and concentrations of radioactive materials in liquid effluents, samples shall be collected continuously whenever the effluent stream is flowing. Prior to analyses, all samples taken for the composite shall be thoroughly mixed in order for the composite sample to be representative of the effluent release.

(6)

Not required unless the Essential Service Water RCFC Outlet Radiation Monitors RE-PRO02 and RE-PRO03 indicates measured levels greater than lx1 06 gCi/ml above background at any time during the week.

(7)

The principal gamma emitters for which the LLD specification applies include the following radionuclides:

Mn-54, Fe-59, Co-58, Co-60, Zn-65, Mo-99, Cs-1 34, Cs-1 37, and Ce-141. Ce-144 shall also be measured, but with an LLD of 5E-06. This list does not mean that only these nuclides are to be considered.

Other gamma peaks that are identifiable, together with those of the above nuclides, shall also be analyzed and reported in the Radioactive Effluent Release Report pursuant to Section 12.6.2, in the format outlined in Regulatory Guide 1.21, Appendix B, Revision 1, June 1974.

(8)

A continuous release, is the discharge of dissolved and entrained gaseous waste from a nondiscrete liquid volume.

12.3.2 Dose Operability Requirements 12.3.2.A The dose or dose commitment to a MEMBER OF THE PUBLIC from radioactive materials in liquid effluents released, from each unit, to UNRESTRICTED AREAS (see Braidwood Station ODCM Annex, Appendix F, Figure F-i) shall be limited:

1.

During any calendar quarter to less than or equal to 1.5 mrems to the whole body and to less than or equal to 5 mrems to any organ, and

2.

During any calendar year to less than or equal to 3 mrems to the whole body and to less than or equal to 10 mrems to any organ.

91 0

Page 11 of 14 Applicability: At all times.

Action:

1.

With the calculated dose from the release of radioactive materials in liquid effluents exceeding any of the above limits, prepare and submit to the Commission within 30 days, pursuant to 10 CFR 50 Appendix I, Section IV.A, a Special Report that identifies the cause(s) for exceeding the limit(s) and defines the corrective actions that have been taken to reduce the releases and the proposed corrective actions to be taken to assure that subsequent releases will be in compliance with the above limits.

Surveillance Requirements 12.3.2.B Cumulative dose contributions from liquid effluents for the current calendar quarter and the current calendar year shall be determined in accordance with the methodology and parameters in the ODOM at least once per 31 days.

Bases 12.3.2.C This section is provided to implement the requirements of Sections II.A, Ili.A and IV.A of Appendix 1, 10 CFR 50. The Operability Requirements implement the guides set forth in Section II.A of Appendix I. The ACTION statements provide the required operating flexibility and at the same time implement the guides set forth in Section IV.A of Appendix I to assure that the releases of radioactive material in liquid effluents to UNRESTRICTED AREAS will be kept "as low as is reasonably achievable." The dose calculation methodology and parameters in the ODCM implement the requirements in Section Ili.A of Appendix I that conformance with the guides of Appendix I be shown by calculational procedures based on models and data, such that the actual exposure of a MEMBER OF THE PUBLIC through appropriate pathways is unlikely to be substantially underestimated.

The equations specified in the ODCM for calculating the doses due to the actual release rates of radioactive materials in liquid effluents are consistent with the methodology provided in Regulatory Guide 1.109, "Calculation of Annual Doses to Man From Routine Releases of Reactor Effluents For the Purpose of Evaluating Compliance with 10 CFR 50, Appendix I" Revision 1, October 1977 and Regulatory Guide 1.113, "Estimating Aquatic Dispersion of Effluents from Accidental and Routine Reactor Releases for the Purpose of Implementing Appendix I," April 1977.

This section applies to the release of radioactive materials in liquid effluents from each reactor at the site. When shared Radwaste Treatment Systems are used by more than one unit on a site, the wastes from all units are mixed for shared treatment; by such mixing, the effluent releases cannot accurately be ascribed to a specific unit. An estimate should be made of the contributions from each unit based on input conditions, e.g., flow rates and radioactivity concentrations, or, if not practicable, the treated effluent releases may be allocated equally to each of the radioactive waste producing units sharing the Radwaste Treatment System. For determining conformance to Operability Requirements, these allocations from shared Radwaste Treatment Systems 92 0

Page 12 of 14 are to be added to the releases specifically attributed to each unit to obtain the total releases per unit.

12.3.3 Liquid Radwaste Treatment System Operability Requirements 12.3.3.A The Liquid Radwaste Treatment System shall be OPERABLE and appropriate portions of the system shall be used to reduce releases of radioactivity when the projected doses due to the liquid effluent, from each unit, to UNRESTRICTED AREAS (see Braidwood Station ODCM Annex, Appendix F, Figure F-i) would exceed 0.06 mrem to the whole body or 0.2 mrem to any organ in a 31-day period.

Applicability: At all times.

Action:

1.

With radioactive liquid waste being discharged without treatment and in excess of the above limits and any portion of the Liquid Radwaste Treatment System not in operation, prepare and submit to the Commission within 30 days, pursuant to 10 CFR 50 Appendix I, Section IV.A, a Special Report that includes the following information:

a.

Explanation of why liquid radwaste was being discharged without treatment, identification of any inoperable equipment or subsystems, and the reason for the inoperability,

b.

Action(s) taken to restore the inoperable equipment to OPERABLE status, and

c.

Summary description of action(s) taken to prevent a recurrence.

Surveillance Requirements 12.3.3.B.1 Doses due to liquid releases from each unit to UNRESTRICTED AREAS shall be projected at least once per 31 days in accordance With the methodology and parameters in the ODCM when the Liquid Radwaste Treatment System is not being fully utilized.

12.3.3.B.2 The installed Liquid Radwaste Treatment System shall be considered OPERABLE by meeting Sections 12.3.1.A and 12.3.2.A.

Bases 12.3.3.C The OPERABILITY of the Liquid Radwaste Treatment System ensures that this system will be available for use whenever liquid effluents require treatment prior to release to the environment. The requirement that the appropriate portions of this system be used when specified provides assurance that the releases of radioactive materials in liquid effluents will be kept "as low as is reasonably achievable". This section implements the requirements of 10 CFR 50.36a, General Design Criterion 60 of Appendix A to 10 CFR 50 and the design objective given in Section 11.D of Appendix I-to 10 CFR 50.

93 0

Page 13 of 14 The specified limits governing the use of appropriate portions of the Liquid Radwaste Treatment System were specified as a suitable fraction of the dose design objectives set forth in Section II.A of Appendix 1, 10 CFR 50, for liquid effluents.

This section applies to the release of radioactive materials in liquid effluents from each unit at the site. When shared Radwaste Treatment Systems are used by more than one unit on a site, the wastes from all units are mixed for shared treatment; by such mixing, the effluent releases cannot accurately be ascribed to a specific unit. An estimate should be made of the contributions from each unit based on input conditions, e.g., flow rates and radioactivity concentrations, or, if not practicable, the treated effluent releases may be allocated equally to each of the radioactive waste producing units sharing the Radwaste Treatment System.

For determining conformance to Operability Requirements, these allocations from shared Radwaste Treatment Systems are to be added to the releases specifically attributed to each unit to obtain the total releases per unit.

Radiological Environmental Monitoringq Program (REMP)

Braidwood ODCM Table 12.5-1 section 3.a, Ground / well water specifies that samples from two sources are required only if they are likely to be affected. Note (6) of ODCM Table 12.5-1 clarifies that groundwater samples shall be taken when this source is tapped for drinking or irrigation purposes in areas where the hydraulic gradient or recharge properties are suitable for contamination. Per discussion with Conestoga-Rovers & Associates and the Exelon Hydrologist, onsite groundwater at Braidwood meets the above criteria. There are drinking water wells in close proximity of the site that could be affected. However, there are no specific groundwater sample locations identified in the REMP. This requirement should be reviewed to determine the groundwater monitoring required to meetthe requirements of Table 12.5-1.

Review of Braidwood ODCM Table 11-1 section 3.a, Ground / well water indicates that there are (5) drinking water wells currently being monitored.

Braidwood ODCM Table 12.5-1 Section 3.a and note (6) to the table discusses the need for groundwater monitoring when the irrigation pathway is a credible pathway. The hydraulic gradient at Braidwood indicates that shallow wells could become contaminated. ODCM Section 4.3 states that the only liquid pathways used are the potable water and fish ingestion pathways. The irrigation to food crop pathway associated with the groundwater contamination should be evaluated. (CAll)

Monitoring for other nuclides 40 CFR 141 and 35 IAC 620 specify limits on radionuclides other than tritium. As part of Braidwood's recovery plan, gamma-emitting fission and activation products as well as other beta-emitting nuclides (Strontium-89, and Strontium-90) are being analyzed.

The gamma-emitting nuclide analytical results indicate normal background levels. Strontium-89 and Strontium-90 results indicate normal background levels.

94 0

Page 14 of 14 Generic Chapters Revision 3 January, 2002 Table 2-1 Regulatory Dose Limit Matrix REGULATION DOSE TYPE DOSE LIMIT(s)3 ODCM EQUATION Liquid Releases:

(quarterly)

(annual) 10 CFR 50 App. V3 Whole (Total) Body Dose 1.5 mrem 3 mrem A-17 (per reactor unit)

Organ Dose (per reactor unit) 5 mrem 10 mrem A-17 Technical Specifications The concentration of radioactivity in liquid Ten (10) times the effluents released to unrestricted areas concentration values listed A-21 in 10 CFR 20 Appendix B; Table 2, Column 2, Table C-6 of ODCM Appendix C for Noble Gases Total Doses 1:

10 CFR 20.1301 (a)(1)

Total Effective Dose Equivalent 4 100 mrem/yr A-25 10 CFR 20.1301 (d)

Total Body Dose 25 mrem/_yr A-25 and 40 CFR 190 Thyroid Dose 75 mrem/yr A-25 Other Organ Dose 25 mrem__/yr A-25 Other Limits 2:

40 CFR 141 Total Body Dose Due to Drinking Water From 4 mrem/yr A-17 Public Water Systems Organ Dose Due to Drinking Water From 4 mrem/yr A-17 Public Water Systems 1 These doses are calculated considering all sources of radiation and radioactivity in effluents.

2 These limits are not directly applicable to nuclear power stations. They are applicable to the owners or operators of public water systems. However, the RETS of some of the Exelon Nuclear power stations require assessment of compliance with these limits. For additional information, see Section A.6 of Appendix A.

3 Note that 10 CFR 50 provides design objectives not limits.

4 Compliance with 10 CFR 20.1301(a)(1) is demonstrated by compliance with 40 CFR 190. Note that it may be necessary to address dose from onsite activity by members of the public as well.

95 1

Root Cause Report Quality Checklist

.Page 1 of 2.

A.

Critical Content Attributes YES NO

1.

Is the condition that requires resolution adequately and accurately identified?

X

2.

Are inappropriate actions and equipment failures (causal factors) identified?

X

3.

Are the causes accurately identified, including root causes and contributing causes?

X

4.

Are there corrective actions to prevent recurrence identified for each root cause and do they tie DIRECTLY to the root cause?

AND, are there corrective actions for contributing cause and do X

they tie DIRECTLY to the contributing cause?

5.

Have the root cause analysis techniques been appropriately used and documented?

X

6.

Was an Event and Causal Factors Chart properly prepared?

X

7.

Does the report adequately and accurately address the extent of condition in accordance with the guidance provided in X of LS-AA-125-1003, Reference 4.3?

8.

Does the report adequately and accurately address plant specific risk consequences?

X

9.

Does the report adequately and accurately address programmatic and organizational issues?

X

10.

Have previoussimilar events been evaluated? Has an Operating Experience database search been performed to determine whether the problem was preventable if industry experience X

had been adequately implemented?

96 1

Root Cause Report Quality Checklist Page 2 of 2 B.

Important Content Attributes

1.

Are all of the important facts included in the report?

X

2.

Does the report explain the logic used to arrive at the X

conclusions?

3.

If appropriate, does the report explain what root causes were X

considered, but eliminated from further consideration and the bases for their elimination from consideration?

4.

Does the report identify contributing causes, if applicable?

X

5.

Is it clear what conditions the corrective actions are intended to X

create?

6.

Are there unnecessary corrective actions that do not address the X

root causes or contributing causes?

7.

Is the timing for completion of each corrective action X

commensurate with the importance or risk associated with the issue?

C.

Miscellaneous Items

1.

Did an individual who is qualified in Root Cause X

Analysis prepare the report?

2.

Does the Executive Summary adequately and X

accurately describe the significance of the event, the event sequence, root causes, corrective actions, reportability, and previous events?

3.

Do the corrective actions include an effectiveness X

review for corrective actions to prevent recurrence?

4.

Were ALL corrective actions entered and verified to X

be in Action Tracking?

5.

Are the format, composition, and rhetoric acceptable X

(grammar, typographical errors, spelling, acronyms, etc.)?

97 2

Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)

Event Timeline Page l of 13 Vacuum Breaker #3 (VB-3)

December 1997 VB-3 was inspected (PM 00079293) with no water leakage noted.

December, 3 to 4, 1998 VB-3 was discovered leaking, due to water hammer failure of the air vent valve line (RC 38237-02).

The Problem Identification Form (PIF) for this event (A1998-04324) was closed to no concern, based on the water being contained onsite and apparently personnel not aware of a tritium concern (Root Cause 4). The PIF stated that the water was in the ditch, which Exelon owns. PIF A1998-04324 stated the repair (temporary) to stop the leak was completed within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> (12/05/1998) under WO 98127749. This section of ditch is blocked at both ends. The size/amount of leakage was not recorded due to a lack of monitoring instrumentation (Other Issue "a"), but was estimated in 2000 to be similar to the 2000 VB-2 leakage at approximately 3 million gallons over a 30-day period.

No integrated spill response procedure was in place to guide adequate station response. ( Root Cause 3)

December 1998 Spill Conclusion In 1998, VB-3 failed and released approximately three million gallons producing standing surface water on Braidwood property.

Problem Identification Form (PIF) A1998-04324

[equivalent to today's Issue Report (IR)] was created to document and address this spill. The response to this event was to isolate the valve and repair the valve as soon as possible. The Braidwood NPDES Coordinator was notified and determined that there were no environmental concerns because the water had not reached a waterway. The environmental procedures concentrate on NPDES compliance associated with oil or hazardous materials and by design, provide no guidance on radiological spills (Failed Barriers 1 & 2).

The Reportability Manual (LS-AA-1 020 & 1110) does not reflect ODCM REMP/RETS reporting requirements for unplanned release paths (Faile.d Barriers 7-11). Also, these procedures do not reflect 35 IAC 620 groundwater tritium requirements (Failed Barriers 7-11). At the time, Operations personnel believed (through interviews) that the water leaking from the CW B/D VB was procedurally treated and approved for radiological release to the environment (Kankakee River) and they assumed it to be radiologically acceptable if it leaked to the ground.

Engineering interviews indicated that they were aware of diluted radioactive waste effluent in the CW B/D line, but since there had been no training for the requirements or the implications of a CW B/D water spill, the creation of a work request and issue report would be an adequate response to correct the leak during the next scheduled work week.

98 2

Vacuum Breaker,#3 (VB-3) and Vacuum Breaker 2 (VB-2)

Event Timeline Page 2 of 13 The Event Screening Committee (the equivalent of today's Braidwood Senior Management Review Committee) reviewed PIF A1998-04324 and assigned no actions to inquire into or address radiological concerns. As a consequence, no action items were created to track the characterization, remediation and documentation of this spill. Radiological concerns were not recognized. There was no documentation that any spill remediation was performed. A root cause for the ineffective response was weak management review and oversight of spill response activities (Root Cause 4).

In this event, the knowledgeable personnel with the radiological expertise were not brought to bear. The root cause was determined to be a lack of integrated procedural guidance to ensure proper recognition, evaluation, and timely mitigation of the spill events (Root Cause 3) to ensure proper identification, timely mitigation and evaluation of the spill events, including knowledge of local hydrology, the impact of low-level tritium leaks, and groundwater regulations.

Documentation associated with the response does not indicate recognition that a potential radioactive spill had occurred. Had it been recognized that the 1998 release of tritium to an unplanned location (the field in the vicinity of VB-3) was a radiological release, a more rigorous characterization and remediation response may have been initiated. A lack of recognition by the Operations Department personnel (who initiate and secure the release of processed radioactive waste into the CW B/D System) and/or the Radiological Protection personnel (who sample and analyze the release tanks prior to concurring with the release), would be a missed opportunity.

Additionally, the 1998 Annual Effluent Report did not contain an evaluation of the vacuum breaker radioactivity released and did not contain the associated evaluation of the dose to the public (IR 455079) & (CA-15). No documentation was located that implied a recognition of vacuum breaker leakage impact on the requirements of the ODCM, REMP, and 10CFR50.75(g).

The root cause of the large volume leaks in 1998 and 2000 is documented in Root Cause Report (RCR) 38237, which determined that the Circulating Water (CW) Blowdown (B/D)

Vacuum Breaker (VB) Valves had inadequate preventative maintenance programs and inadequate design configuration (Root Cause 1).

November 15, 2000 Condition Report (CR) A2000-04389 was written which stated that the 1998 response to PIF Al 998-04324 was inadequate, as a result of Root Cause Report (RCR) 38237/CR A2000-04281.

CR A2000-04389 resulted in an action to Radiation Protection to perform a radiological evaluation under 10 CFR 50.75(g). June 18, 2001 99 2

Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)

Event Timeline Page 3 of 13 CR A2001-01806 reported VB-3 leaking.

WC-AA-106 did not have tritium concerns integrated into the work prioritization. At this time, there was no guidance in the CW B/D procedures to secure radiological releases when known leaks were discovered. (Root Cause 3)

Note: Little to no information could be found in PIF's or WR/WO's for this event.

Therefore, little data could be retrieved by this Root Cause Investigation Team (IR 428868) other than from personnel interviews.

July 21, 2001 CR A2000-04389's 10 CFR 50.75(g) Radiological Assessment Report was completed based on samples obtained in April 2001.

In retrospect, the 1998 VB-3 spill site was inadequately characterized, due to the lack of groundwater assessment for tritium concentrations.

Therefore, the evaluation erroneously concluded that there was no further action required.

July 23, 2001 Revision 2 of WO 98127749 to repair VB-3 is authorized for work by Operations. The WO comments stated that leaking water prevented work completion. The WO did not contain precautions regarding tritium leakage, due to ATI 106767-04 (May 2002) comments not being incorporated into the WO. (Other Issue "b")

December 2001 VB-3 was inspected (WO 99284438) with no water leakage noted.

May 4, 2002 VB-3 pilot (air release) valve seat was discovered leaking water. WO 004402131 and IR 106767 were written.

100 2

Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)

Event Timeline Page 4 of 13 May 20, 2002 Revision 2 of WO 98127749 to repair the isolation valve for VB-3 was completed, with no mention of radiological controls for the water discovered in the vacuum breaker pit. (Root Cause 3)

August 29, 2003 Water was found in the VB-3 valve pit during walkdown surveillance. WR 00110407 and IR 173688 were written. The IR indicates water is most likely groundwater intrusion into the pit. There was no observed leakage from VB-3.

March 17, 2005 The Illinois Environmental Protection Agency (IEPA) contacted Exelon concerning an investigation of tritium concentrations in wells near Braidwood Station in preparation for the Godley public hearing. Sampling to investigate this report was commenced.

(IR 328451)

November 30, 2005

  • Issue Report (IR) 428868 reports tritium concentrations from what appears to be the area of the 1998 spill, have migrated offsite with a potential to affect the public via tritiated groundwater. (EVENT)

Vacuum Breaker 2 (VB-2)

December 1996 VB-2 was inspected (PM 00079293) with no water leakage noted.

January 5, 1998 Water leak discovered on the VB-2 pilot (air release) valve seat. WR 9800691 was written.

101 2

Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)

Event Timeline Page 5 of 13 May 24, 2000 VB-2-found leaking. Issue tracked via WR 9800691.

November 6, 2000 14:30 The Braidwood National Pollutant Discharge Elimination System (NPDES) Coordinator received a call from the Illinois Environmental Protection Agency (IEPA) regarding standing water in a ditch immediately adjacent to private property along the south side of Smiley Road. An area resident had reported the water and noted that the water had been present in the ditch for approximately 7-10 days prior to IEPA notification.

Suspecting a faulty vacuum breaker, the NPDES Coordinator notified the Shift Manager and Outage Control Center (OCC) Director of the IEPA notification.

November 6, 2000 15:00

  • The Braidwood NPDES Coordinator walked down the Circulating Water Blowdown system and identified that the water was coming from a valve vault that houses VB-2.

The NPDES Coordinator assessed the site and concluded that the water was confined to site property which included the ditch along the south side of Smiley Road.

  • The Braidwood NPDES Coordinator notified the IEPA of his findings regarding the water source and the boundaries of the discharge. Station NPDES monitoring requirements were discussed and the IEPA requested no additional sampling. The Braidwood NPDES Coordinator determined that there were no NPDES concerns since the water was contained and not discharging to "Waters of the State".

The VB-2 leakage was estimated to be a maximum of 3 million gallons. This leakage was the result of corrosion of the vacuum breaker assembly and water hammer, which broke the float in VB-2, exposing an 8" opening.

102 2

Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)

Event Timeline Page 6 of 13 November 6, 2000 16:00 -17:00 A meeting was held with Braidwood Senior Management, the Shift Manager and the Outage Control Center (OCC) staff. The Braidwood NPDES Coordinator briefed the attendees on the results of his field observations of the area surrounding the vacuum breaker valve.

Braidwood Senior Management was also briefed on the discussions between the Braidwood NPDES Coordinator and the IEPA.

Braidwood Senior Management directed the following actions be taken:

1.

Operating personnel were to evaluate water inventories and to explore potential alternate release options.

2.

Isolate the CW B/D system

3.

Make preparations to take the CW B/D system out of service, drain the piping section and replace the failed vacuum breaker valve.

The CW B/D system was then isolated in preparation for draining and repairs. There was no discussion at this time of any need to sample for radioactivity in the water that had been discharged. The thought process was that any radioactivity in the water had been diluted per procedure and was acceptable for discharge to the environment (i.e., the Kankakee River). [This is based on Operations Department personnel interviews.]

November 7, 2000 06:15 The Braidwood Operations Manager notified the Braidwood Radiation Protection (RP)

Manager that there was a blowdown line leak and that RP was to meet with the Braidwood Chemistry Manager to look at potential alternate radioactive release paths.

The reason for this request was that radioactive releases would not be possible via the blowdown system while blowdown was isolated for repairs to VB-2.

Following this phone conversation, the Braidwood RP Manager notified the Braidwood RP Technical Superintendent regarding the need to collect samples of available water.

103 2

Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)

Event Timeline Page T7of 13 November 7, 2000 08:00 A decision to conduct confirmatory sampling of the water leaking from the manway cover of the vacuum breaker structure was made.

The sample was taken at approximately 0845 and the results of the gamma isotopic analysis indicated no detectable radioactivity. Isotopic analysis indicated no detectable tritium.

Braidwood chemistry manager contacts corporate environmental and asks them to report to the site to help assess the event.

Decision is made by Braidwood Senior Management to sample both soil and water at the vacuum breaker.

November 7, 2000 08:30 Mechanical Maintenance Department (MMD) personnel with assistance from System Engineering pumped out the VB-2 vault back into the B/D line and began draining the blowdown piping to facilitate work on VB-2.

November 7, 2000 11:30 Braidwood RP received information that the leak may have occurred for a period of 7-10 days and that the water that leaked was from the circulating water blowdown line, which carries the liquid radiological discharges from the station to the river.

November 7, 2000 12:00

  • After the CW B/D line had drained sufficiently, the entire VB-2 isolation valve and vacuum breaker assembly was replaced.

104 2

Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)

Event Timeline Page8of 13 a November 7, 2000 12:30 A decision was made to initiate soil sampling in the vicinity of the vacuum breaker structure, and to obtain a water sample from the standing water that was onsite, but near the Smiley Road ditch.

November 7, 2000 13:00 Braidwood RP Manager and Station Manager discuss and agree to additional sampling.

Plan was approved.

November 7, 2000 18:00 Braidwood management talked with local residents to explain the issue.

November 7, 2000 19:00 The results of the samples from November 7, 2000, were discussed with corporate Generation Support Department (GSD) RP Manager. Corporate GSD agreed to discuss the issue with the corporate GSD General Manager.

November 7, 2000 19:45 The Station Manager and Site Vice-President (VP) were notified of the sample results. A total of 5 soil samples were obtained within approximately 30 feet of the vacuum breaker VB-2 structure, and 2 of the 5 soil samples had detectable levels of radioactivity. The onsite soil sample obtained near the Smiley Road ditch was analyzed indicated no gamma radioactivity, and water analysis from the location indicated tritium at 35,000 pCi/L.

November 7, 2000 21:15 Circ water blowdown is restored.

105 2

Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)

Event Timeline Page9of 13 November 8, 2000 08:30

  • The Braidwood RP Manager discussed the sample results on the morning call.

November 8, 2000 14:00

  • The Braidwood RP Manager, Chemistry Manager, Regulatory Assurance Manager, Station Manager, and Site VP met to discuss the current status, next steps, and sampling for the event.

November 8, 2000 16:00 Additional onsite sampling of the standing water in the area leading to the Smiley Road ditch was performed. Four water samples were taken and results indicated tritium levels ranging from 35,000 to 53,000 pCi/L.

No gamma isotopic activity was detected in the water.

November 8, 2000 18:00 Conference call between site and corporate regarding test results and proposed actions.

November 9, 2000 10:00 A conference call was held with the Site Management and Corporate Personnel to finalize and approve an Offsite Sampling Plan, a Remediation Plan, and a Communications Plan.

At 12:00, discussions were held with site and regional NRC personnel. At 1210, notification of the offsite release was made to Will County authorities and to the Reed Township Highway Commissioner.

At 12:45, RP was dispatched to obtain water samples from the Smiley Road ditch.

106 2

Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)

Event Timeline Page 10 of 13 November 9, 2000 14:00 Four water samples were obtained from the Smiley Road ditch. Gamma isotopic analysis indicated and the tritium analyses ranged from 19,000 pCi/L to 25,000 pCi/L NQPF.

Teledyne Isotopes Midwest Laboratory also analyzed these samples with similar results.

November 9, 2000 17:30 The NRC Regional Office and Illinois Department of Nuclear Safety (IDNS) were notified of the Smiley Road ditch sample analyses results.

November 10, 2000 01:00 IDNS came to the site to take (4) samples from the Smiley Road ditch.

November 10, 2000 11:00 Pumping of the water back to the blowdown line commenced. Pumping continued using a 600 gpm pump, approximately 18 hours2.083333e-4 days <br />0.005 hours <br />2.97619e-5 weeks <br />6.849e-6 months <br /> per day.

  • Corporate led remediation team formed and OP-AA-101-503 "NGG Issue Management Worksheet" was entered. Attachment 2 (action plan) of this procedure was created and approved.

November 2000 Spill Conclusions In 2000, VB-2 failed and released approximately three million gallons to the Braidwood Station grounds. A local resident observed and reported the spill to the Illinois Environmental Protection Agency (IEPA), who in turn notified the Braidwood Station National Pollutant Discharge Elimination System (NPDES) Coordinator. The NPDES Coordinator wrote PIF A2000-04281 and notified the Illinois Department of Nuclear Safety (IDNS), the Illinois Emergency Management Agency (IEMA) and Braidwood Senior Management. The Braidwood Radiation Protection (RP) Manager and the RP Technical Superintendent discussed the need to collect samples of available water at VB-2. The sample results indicated >20,000 pCi/L tritium was present in the spilled water.

The immediate response to this event was to shutdown the blowdown system, repair the valve as soon as possible, and engage Senior Corporate Management to create a spill response plan.

107 2

Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)

Event Timeline Page 11 of 13 A Senior Corporate Manager was chosen to assemble and direct an Issues Management Team (IMT).

Although knowledgeable personnel supported the IMT, there was no integrated procedure in place to ensure that all necessary actions were completed (Root Cause 3). As a result, the groundwater tritium was not properly characterized and remediated.

The IMT entered four (4) Corporate procedures, which provide guidance to identify, evaluate, remediate and communicate the radiological concerns. The four (4) procedures were:

NSP-RP-61 01, "10 CFR 50. 75(g)(1) Documentation Requirements" 0 CWPI-NSP-1 -1, "CAP Process Manual of Common Work Practice Instructions -

Instruction on Event Response Guidelines' OP-AA-1 01-501, "NGG Significant Event Reporting' 0 OP-AA-1 01-503, "NGG Issues Managemenf'.

However, no historical documentation could be located to demonstrate that the procedures (other than NSP-RP-61 01) were fully executed. There is no evidence of the use of Passport for the documentation of the IMT plans and activities as required by OP-AA-101-503, "NGG Issues Management". This root cause team interviewed (by telephone) the Corporate Senior Manager who was assigned to manage the Issues Management Team. He was questioned concerning the execution of the IMT's responsibilities. The Corporate Senior Manager had little recollection of the details of the team's response.

Although that Corporate Senior Manager had the responsibility to manage the IMT's completion of characterization and remediation plans and would normally be held accountable, he is no longer employed by Exelon. This indicates weak management review and oversight of spill response activities. (Root Cause 4)

The IMT developed separate soil sampling plans and water sampling plans flowcharts (decision trees).

For soil, all documentation was done within the station 10 CFR 50.75(g) procedure, NSP-RP-6101.

For water, the sampling plan included a review of the tritium in the water and implementation of a Remediation/Control Plan. Notes on the water sampling plan indicate that the team considered: 1) pumping the water back into the blowdown line and 2) well monitoring.

The IMT had also recognized the need to evaluate local hydrology for potential impact of the tritiated spill in groundwater as referenced in a contractor's proposal for the implementation of a Stage 1 and Stage 2 plan.

Stage 1 included the installation of wells to assess the local hydrology to determine groundwater gradients and movement.

This stage of the plan was executed by the IMT. Stage 2 of the plan included sampling of the groundwater to determine mixing model and surface infiltration into an aquifer. Stage 2 of the plan was not executed.

The water was pumped back into the B/D line on 11/10/00 and hydrology wells were installed in the area of the 2000 leak to characterize the local hydrology. The contractor report specified that the groundwater in the area of VB-2 would take 15 years to travel the 800 feet to reach the property line.

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Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)

Event Timeline Page 12 of 13 The report then clarifies that the flow velocity would not apply to the surface water that apparently flowed from the valve box, over the land surface, and to the ditch along the road.

The remediation efforts were halted after the surface water was pumped back into the B/D line Although no documentation exists for the basis behind the decision to not perform groundwater sampling, a review of IMT data and, notes has lead the Root Cause Investigation Team to Conclude that the following information was considered in the decision making process:

The spilled water had already been approved for release. Therefore, it was already determined to meet concentration limits for release to the public. The team assessed the impact of the radiological spill against known reporting requirements. The Illinois Groundwater statute was absent from the list in the IMT notes (Causal Factor 4).

  • The hydrology study indicated that it would be. 15 years before groundwater in the area of VB-2 would migrate offsite to potentially impact offsite drinking water wells. At that rate, the tritium concentration would be below drinking water standards, potentially even below detectable levels, by the time it reached the site boundary due to radiological decay and, potentially, dilution. [Today, hydrology experts state that once the tritium enters the groundwater, dilution does not significantly occur.]

Further efforts included a 10 CFR 50.75(g) characterization study. The 2000 10 CFR 50.75(g) focused primarily on soil sampling.

The 10 CFR 50.75(g) study does reference the tritium concentrations that were found in the standing water. The 10 CFR 50.75(g) study did not direct groundwater sampling for tritium nor assess the environmental impact of the spilled tritium (Failed Barrier 3). The 2000 RCR Team required an analysis of the 2000 leak 10 CFR 50.75(g) by an independent Certified Health Physicist and approval by Braidwood Senior Management, however, this analysis did not include tritium.

As a result, the groundwater tritium went undetected until the 2005 tritium sampling discovered it. This indicates weak management review and oversight of spill response activities. (Root Cause 4)

The year 2000 leak from Vacuum Breaker (VB) 2, RCR # 38237 documented 5 CW B/D vacuum breaker spills. Two of these released a large volume of water. The root-cause of these leaks was inadequate preventative maintenance programs and inadequate design configuration (Root Cause 1).

Effectiveness Review (EFR) of the Corrective Actions to Prevent Recurrence (CAPRs) of large volume leaks determined that the CAPRs were effective at resolving the Root Cause. However, the Root Cause was narrowly defined, only evaluating the large volume valve leaks and not considering radiological impacts from the spills due to a lack of technical rigor (CAPR 3 and CAPR 5 address this issue).

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Vacuum Breaker #3 (VB-3) and Vacuum Breaker 2 (VB-2)

Event Timeline Page 13 of 13 The 2000 Root Cause Report (RCR) Team discovered the large volume 1998 VB-3 leak and wrote PIF A2000-04281 to have the 1998 spill reviewed per procedure # NSP-RP-6101 for residual radioactivity under 10 CFR 50.75(g). The soil sampling conducted as part of the 10 CFR 50.75(g) process indicated similar deposited radionuclides in the soil as that found during the 2000 leak. However, tritium was not addressed (Failed Barrier 3).

Braidwood Senior Management and Exelon Corporate Senior Management did not track characterization and mitigation plans to completion during and following the year 2000 spill.

Although the 2000 Annual Effluent Report did report the 2000 vacuum breaker leakage as an unplanned release, it did not contain a proper assessment of the dose to the public. The 1998 Annual Effluent Report was not amended to report the 1998 vacuum breaker leakage (discovered in 2000) and associated dose to the public (IR 455079) & (CA-15).

HU-AA-102 and -1212, Technical Human Performance Practices and Technical Task Risk/Rigor Assessment, Pre-Job Brief, Independent Third Party Review, and Post-Job Brief procedures have been instituted to improve technical rigor, questioning attitude, and attention to detail (CAPR 3). OP-AA-106-101-1002, Exelon Nuclear Issues Management, will be revised to: 1) improve Corrective Action Program (CAP) controls of Issue Management Teams, 2) utilize the tools and techniques of the Exelon HU-AA-102 and -1212, Technical Human Performance Practices and Technical Task Risk/Rigor Assessment, Pre-Job Brief, Independent Third Party Review, and Post-Job Brief procedures, 3) strengthen reporting requirements to station Senior Management, and 4) define station Senior Management responsibilities oversight and challenge of events and issues from initiation to final disposition (CAPR 5).

An email from an RP supervisor who attended an exit meeting for an NRC REMP (radiological effluent monitoring program) inspection (NRC Inspection Report Braidwood 2001-0005) provided the following information. The Nuclear Regulatory Commission (NRC) reviewed the 2000 Root Cause (RC 38237) (documented in NRC Inspection Report Braidwood 2001-0005) and had a recommendation to sample residential wells in the area of concern "just to see negative results from these locations to support future cleanup activities" (documented only in the email). A second comment from the NRC review was that the root cause only focused on the equipment issues and not on spill recovery aspects. No documentation could be found to show that the Issues Management Team or Braidwood Senior Management reacted to these NRC's observations. This response reflects a weak management review and oversight of spill response activities (Root Cause 4).

A contributing cause to this overall event was a weak questioning attitude and an inadequate challenge culture by Braidwood Senior Management regarding the 17 CW B/D leaks over the 10 year period bridging 1996 to the present.

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