ML20209F235

Nonproprietary Rev 1 to Insp Rept 70-1113/86-22 on 861006- 10.Violation Noted:Failure of Licensee to Provide Annual Participation to Local Fire Depts in Onsite Fire Drills & Eight Weaknesses & 47 Improvement Items Identified

ML20209F235
Person / Time
Site:	07001113
Issue date:	04/13/1987
From:	Alpine E, Bidinger G, Garner L, Kahle J, Madden P, Sjoblom G, Tabaka A NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
To:
Shared Package
ML20209F156	List: ML20209F151 ML20209F193 ML20209F235
References
70-1113-86-22, NUDOCS 8704300238
Download: ML20209F235 (49)

Text

WE UNITED STATES

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Report No.: 70-1113/86-22, Rev. 1 Licensee: General Electric Company Wilmington, NC 28401 Docket No.: 70-1113 License No.: SNM-1097 Inspection Conducted: October 6-10, 1986 Inspectors: Ohdit J/S'7 Da'te Signed J.jB.A able, Team Leader FueF Facility Project Manager, NRC, RII

. d 3 E A. E abaka, Radiation Specialist, NRC, RII Date Si ned

. QfkAWI?h 4b3 s 7 Date 41gned P. M yadden',~ Fire Pfotection Engineer, NRC, RII F 0w CLLl . - L 4hv h 7 L. W. Gafner, Residen6 Inspector,lNRC, RII Date Signed (Brunswick)

Fhw h 1 G. H. Bidinger, Licensh Project . Manager, NRC, NMSS 4h y /97 Date Signed EONYse OLAh b 4/lV /07 G. L. Sjdblom, Chief \ l Date Signed Safeguards and Materials Programs Branch, NRC, IE-HQ Accompanying Personnel: W. E. Cline, Chief Nuclear Material Safety and Safeguards Branch, NRC, RII R. A. Horner, Chemical Engineer, EPA-HQ W. P. Boone, Health Compliance Officer OSHA, North Carolina C. W. Johnson, Safety Compliance Officer t OSHA, North Carolina D. McDaniel, Safety Compliance Officer OSHA, North Carolina Approved by: NM "

E. J. McAYpine, Chief \ '

4./lV /2 7 Date Signed Material Control and Accountability Section Nuclear Materials Safety and Safeguards Branch Division of Radiation Safety and Safeguards 8704300238 870414 3 PDR ADOc% 0700 C

SUMMARY

Scope: This special, announced inspection involved an operational safety assessment of the chemical conversion, scrap recovery, waste treatment, and hydrogen sintering furnace areas to determine whether there are potential operational safety hazards which, when combined with facility operations, could adversely impact the health and safety of the public or workers at the plant.

Results: One violation was identified - failure of the licensee to provide for annual participation of the local fire departments in on site fire drills. In addition, eight weaknesses and 47 improvement items pertaining to the operational safety of the four areas indicated above and relating to management control, emergency contingency plan, fire protection, nuclear criticality safety, maintenance and surveillance of instruments and controls, and chemical process safety programs were identified.

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TABLE OF CONTENTS I. REPORT DETAILS I------------------------------------------------------I

1. Persons Contacted------------------------------------------------I

2. Exit Interview---------------------------------------------------2

3. Inspection Scope-------------------------------------------------2

a. Supporting Federal and State Agencies------==-- ==----------2

b. Assessment Methodology--------------------------------------2

4. Plant Operations-------------------------------------------------3

a. Chemical Conversion-----------------------------------------3

b. Scrap Recovery and Waste Treatment--------------------------3

c. Hydrogen Sintering Furnaces---------------------------------4

5. Management Controls----------------------------------------------4

a. Safety Review Systems---------------------------------------4

b. Operating Procedures----------------------------------------5

6. Nuclear Criticality Safety---------------------------------------6

a. Conversion Area---------------------------------------------6

b. Scrap Recovery ---------------------------------------------7

c. Waste Treatment Area----------------------------------------8

d. Hydrogen Sintering Furnace Area-----------------------------9

e. Summary of Nuclear Criticality Safety Findings--------------9

7. Fire Protection / Prevention Program------------------------------11

a. Assessment of Administrative Control Procedures------------11

b. As sessment of Licensee 's Organi zation----------------------13 l c. Inspection and Maintenance Program-------------------------14

d. Site Emergency Response Team (Fire Brigade)----------------16

e. Inspection of Fire Protection Equipment--------------------21

8. Chemical Process Safety-----------------------------------------22

a. General----------------------------------------------------22

b. Audit of SOPS for Chemical Safety--------------------------24

c. Chemical Handling Safety-----------------------------------24 i

9. Operations Engineering---------------------------------- -------25 l a. Calibration Program----------------------------------------25

b. Maintenance Activities-------------------------------------28 i c. Surveillance Activities------------------------------------30

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Table of Contents 2

10. Evaluation of Accident Potential---------------------------------32

a. Fire--------------------------------------------------------32

b. Nuclear Criticality Safety----------------------------------33

c. Uranium Hexafluoride Vaporization---------------------------34

d. Acci dent Pote nti al S umma ry----------------------------------34

11. Radiological Contingency. Plan------------------------------------35

a. Scope-------------------------------------------------------35

b. Offsite Agency Coordination and Training--------------------35

c. Emergency Classification and Notification-------------------36

d. Emergency Facilities and Equipment--------------------------38

e. Training----------------------------------------------------40

f. Administration and Maintenance of Program-------------------42

g. Miscellaneous-----------------------------------------------44 I

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REPORT DETAILS

1. Persons Contacted Licensee Employees

• E. A. Lees, Manager, Nuclear Fuels and Components Manufacturing

• W. W. McMahon, Manager, Quality Assurance

• J. A. Bergman, Manager, Fuel Manufacturing

• J. L. Harmon, Manager, Technology and Automation

• D. W. Brown, Acting Manager, Fuel Production Operations

• R. M. McIver, Manager, Plant Engineering

• R. C. Pace, Manager, Powder Production

• D. A. Burns, Manager, Materials Services .

• L. A. Divins, Manager, Chemical Manufacturing Engineering

• J. H. Bradberry, Manager, Emergency Preparedness and Security

• J. H. Faucette, Manager, Employee and Community Relations

• R. G. Patterson, Manager, Fuel Manufacturing Engineering

• G. W. McKenzie, Technology and Automation Engineer f

• A. G. Dada, Manager, Chemical and Ceramic Engineering L

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• R. A. Petelinkar, Manager, Site Operations and Materials Systems

• R. L. Torres, Manager, Radiation Protection

• C. M. Vaughan, Manager, Regulatory Compliance

• G. M. Bowman, Acting Manager, Nuclear Safety Engineering

• B. J. Beane, HVAC Engineer

• S. P. Murray, Senior Nuclear Safety Engineer

• W. B. Smalley, Manager, Environmental Programs

• J. A. Taylor, Senior Nuclear Safety Engineer

• F. A. Welfare, Senior Nuclear Safety Engineer

• R. Robinson, Manager, Programs and Staffing

• J. F. Wolfe, Manager, Industrial Safety

• P. D. Godwin, Fire Safety Technician

• M. E. Wall, HVAC Engineer / Supervisor

• B. S. Dunn, Specialist, Licensing Support

• R. H. D. Foleck, Senior Specialist, Licensing Engineering R. K. Hollys, RN, Site Medical Services Dr. C. J. Schmit, Physician, Site Medical Services R. G. Lewis, Shift Supervisor, Radiation Protection F. D. Reynold, Supervisor PPU, Chemical Conversion P. S. Stansberry, Senior Nuclear Safety Engineer The inspectors also interviewed other licensee employees.

Other Organizations J. McQueen, Jr. , Sheriff, New Hanover County M. R. Murray, Emergency Services, New Hanover County Memorial Hospital K. R. Hines, Head Emergency Clerk, New Hanover County Memorial Hospital D. Summers, Coordinator Emergency Services, New Hanover County L. H. Long, Chief, Wrightsboro Volunteer Fire Department G. R. Padgett, Chief, Castle Hayne Volunteer Fire Department

• Attended exit interview i

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2. Exit Interview The assessment scope and findings were summarized on October 10, 1986, with those persons indicated in paragraph 1 above. The violation relating to failure of the volunteer fire departments to participate in annual on site drills was discussed in detail. No disse ~nting comments were received from the licensee. The weaknesses and improvement items identified during the assessment were related to licensee management. Licensee management was also informed that NRC is supportive of the planned North Carolina OSHA enforcement action relating their findings. The North Carolina OSHA report will be issued separately.  :

During the exit interview, the licensee's technical review pertaining to cooling of UF6 cylinders with CO2 was discussed. The licensee agreed to provide NRC with a copy of their report on this matter (IFI 86-22-01).

3. Inspection Scope

a. Supporting Federal and State Agencies To broaden the perspective of this safety assessment, EPA and OSHA were requested to assist NRC in conducting the operational safety team assessment. These organizations cooperatively responded in a very active participative and consultive capacity. North Carolina OSHA personnel were currently conducting an inspection of the activities at General Electric's Wilmington plant when the team assessment started.

Consequently, their report (s) pertaining to industrial safety, industrial health and hygiene and fire protection will be issued by their agency. The EPA findings are included in this inspection report.

b. Assessment Methodology The assessment involved identification of accident potentials, determination of the adequacy of controls to prevent accidents, review of the licensee's maintenance and surveillance programs which assure that controls would be operative to prevent an accident, and assessment of the licensee's ability to mitigate the effects and consequences should an accident occur. Programmatic assessments were performed of management controls, emergency contingency plans, nuclear criticality safety, fire protection, chemical process safety and operations engineering (instruments and controls). Four systems and processes operated by the licensee which had the highest potential risk (in NRC's opinion) were selected for the assessment. These were chemical conversion, scrap recovery, waste treatment, and hydrogen sintering furnace operations.

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4. Plant Operations

a. Chemical Conversion Uranium hexafluoride (UF6) enriched in Uranium-235 up to 4.0 percent is vaporized from the solid form in 2.5 ton, 30 inch diameter cylinders (Models 30A and 30B).

In the ammonium diuranate (ADU) process, the UF6 gas is hydrolyzed to uranyl fluoride (UO2F2) and hydrofluoric acid (HF). The hydrolyzed UF6 is precipitated with ammonium hydroxide to form ADU. The ADV slurry is centrifuged to partially remove liquids with the remaining solids introduced to a defluorination-reduction furnace (calciner). The calciner has a steam-dissociated ammonia reducing atmosphere where fluorides are removed and the uranium is reduced to an oxide form.

In the direct conversion (GEC0) process, the UF6 gas is fed to a reactor vessel along with controlled flows of air and hydrogen to convert the uranium to an oxide form. The oxide form is further treated in a calciner unit to remove fluorides and to convert the oxide (U308) to a desired 002 powder.

b. Scrap Recovery and Waste Treatment Several scrap recovery and waste treatment operations are utilized to recovery uranium and to treat wastes and reduce the quantity of contained uranium and other chemicals to below regulatory (NRC, EPA, State, and local agency) limits.

Solids are dissolved in nitric acid and precipitated with ammonium hydroxide and hydrogen peroxide to form uranium tetroxide (UO4). The

, recovered uranium.(UO4) is fed to the defluorination-reduction furnace l (calciner) as part of the chemical conversion process stream. The operation is being discontinued because of problems associated with hydrogen peroxide and the development of improved recovery methods associated with the installation of the uranium process management project (UPMP).

UPMP is a company proprietary scrap recovery and waste treatment I operation. In UPMP, three liquid waste streams (fluoride, nitrate and radwaste) from the chemical conversion processes are treated to remove and recover the uranium solids. The liquids are treated at the waste treatment facility for removal of chemicals prior to release from the l plant site. The solids are processed in an oxidizing furnace, l dissolved, sent to a solvent extraction process to recover uranium.

' The licensee operates a decontamination facility to remove uranium from equipment prior to waste disposal. Combustibles, contaminated with uranium, are placed in large wooden boxes and incineratcc. The ash material is processed for recovery of uranium in the UFMP facility.

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c. Hydrogen Sintering Furnaces The hydrogen sintering furnaces are large electrically fired furnaces which are used to sinter pellets in a hydrogen controlled atm'osphere.

5. Management Controls

a. Safety Review Systems The team assessed the effectiveness of the company management systems related to operational safety. This assessment was based on interviews with management, including the plant manager and managers of manufacturing, quality assurance, regulatory compliance, licensing, nuclear safety, radiological protection, industrial safety, uranium powder production, as well as plant tours and discussion with supervisors and operators. Various plant records were also examined including corporate policy statements, systems for nuclear safety audits, facility and procedure change requests, practices and procedures, safety manuals, emergency plans, selected training and qualification records and procedures. In addition, the team reviewed the actions that have been taken by the licensee to enhance safety of UF6 handling at the plant as a result of the lessons learned from the accident at Kerr-McGee facility in Oklahoma in January 1986.

The team concluded that the management of the plant is committed to ensuring safe operation of the facilities in which licensed material is handled, and that management systems and procedures in place are generally adequate to this end.

The team observed that none of the 24 changes since 1974 to the procedure covering vaporization of UF6 have been processed through and documented in the formal review system. While most of these changes may have had relatively minor safety significance, the recent ones made as a result of the lessons learned from the accident in Oklahoma did have safety importance. Review and documentation in this formal system ensure that the analyses are included in the formal record system and ensure the very important reasons for the changes are not lost in future years. The licensee should consider this item for improvement by establishing criteria for those changes which must be reviewed in order to make better use of the established system (IFI 86-22-02).

The licensee's system for followup on plant incidents was reviewed.

The team determined that the licensee's program for determining trends and root causes from incident evaluation and followup, was weak. The licensee should consider categorizing incidents in ways to provide early warnings of trends or underlying causes of various types of repeated incidents. The categorization and trending and root cause

., investigative methods should be documented in the Plant Safety Manual and/or as part of Practices and Procedures. This matter is considered a program weakness and warrants licensee attention (IFI 86-22-03).

5 The team reviewed the actions taken by the licensee as a result of the lessons learned from the Sequoyah accident to enhance the safety of operations involving UF6 at the licensee's facility. These actions included providing additional emergency exits from the vaporization room, prohibiting maintenance in the area above the vaporization -

chambers during vaporization operations, checking certain important instrumentation, and stopping the use of liquid CO2 for normal cooling of heated UF6 cylinders. The licensee is continuing to review this area. The team considered these actions appropriate.

The licensee conducted analyses of the use of liquid C02 for cooling heated UF6 cylinders and made certain changes in the operating procedures that would not permit normal use of CO2 for this purpose.

The licensee agreed to provide these technical reports and analyses to NRC for review. This information would be useful to NRC to review the technical conclusions made by the licensee and to help determine if conditions warrant any appropriate action at other licensee facilities.

b. Operating Procedures The licensee's UF6 vaporization procedures were reviewed and discussed with licensee representatives. Of particular concern was the lack of detail in the safety steps delineated in PROD 10.05, dated 8/18/86, entitled " Equipment Operating Instruction Vaporization" for ADU and GECO. The need for clear, explicit safety instruction was emphasized to the licensee. This matter is considered a weakness and should be addressed by the licensee (IFI 86-22-04). Details of the above \

procedural weakness are:

(1) Paragraph 2.5 describes the CO2 emergency cooling equipment which can be used in an emergency to cool either a heated UF6 cylinder body or the cylinder valve. Paragraph 3.1 requires checking the operability of the CO2 system before installing a UF6 cylinder into a chamber. Exhibit 2, part A described conditions under which CO2 would be used to freeze the cylinder valve to isolate a leak if the leak is detected by the floor operator but part B does not provide conditions under which C02 would be used te 7waeze the cylinder valve if the leak is detected by the UF6 dotet ors and

, registered in the control room. This i ncon si s"ere. se .ild be j resolved. Furthermore, nowhere are conditions dest.qco shen CO2 would be used to cool the cylinder body. In fact, Exhibit 2 specifically prohibits turning on UF6 cylinder C02. Nevertheless, Exhibit 2, paragraph C, Special Notes alludes to use of CO2 on a UF6 cylinder, valve or plug. If there are conditions under which CO2 can safely or should be applied to the cylinder or plug, these

should be specified in the procedure.

(2) Section A of the procedure requires the floor operator to evacuate the room and activate emergency ventilation if he sees a UF6 leak from a chamber but tells the operator he should don a mask and l

open a chamber to investigate if the UF6 leak detector alarm i  ?

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activates in the control room. This appears to be a difficult decision for an operator to make in an emergency condition. The procedure for a leak should be independent of the means of detection of a leak. The current procedure could cause operator confusion and possibly unsafe action. The licensee should consider an initial protective measure such as evacuation --

followed by controlled reentry into the vaporization room upon consultation with the control room and upon arrival and posting of assisting persons at the door of the vaporizer room.

(3) The procedure calls for one-inch and two-inch oak plugs to be available but does not state the conditions under which such plugs would be used or provide any guidance or equipment on how they would be used.

(4) It was noted that there is normally only a single floor operator in the vaporization / warehouse area. The licensee should review whether this provides adequate safety of operation as well as adequate protection of the operator in the event of a large UF6 release.

6. Nuclear Criticality Safety

a. Conversion Area (1) Licensee's Nuclear Criticality Safety Controls In the ADU conversion area, the licensee relies primarily on favorable geometry control to assure nuclear criticality safety.

In the vaporization area, the GECO conversion area, and the powder storage areas, the primary nuclear safety control is moderation control. Liquid wastes are subject to concentration control and solid wastes are subject to mass control. Mass control is also imposed on many of the units which are subject to favorable geometry control.

(2) Adequacy of Nuclear Criticality Safety Controls The basis for safety starts with a corporate policy (NEDE 24697) which establishes the number of criticality controls which must be provided and the margins of safety for normal and potential upset conditions. Some of the policy requirements have been incorporated into the SNM license for the Wilmington facility.

NEDE 24697 establishes a hierarchy of controls. The preferred control is a passive one such as favorable geometry design. The next type of control is an automatic engineering control (AEC).

The third and least preferred type of control is administrative in nature, e.g., mass control.

7 The specific nuclear criticality safety controls for a process station are identified by a documented safety analysis and an independent technical review. Both the analysis and review are performed by personnel who possess, as a minimum, the qualifications specified in the license. For changes to existing facilities, area management initiates a Facility Change Request (FCR) form. Nuclear Safety Engineering (NSE) personnel review the FCR to determine whether a criticality control evaluation is needed. Area management or project management may have to supply additional information which is also documented. When the criticality control evaluation is completed, NSE management and area management approve the criticality controls for the proposed activity. Approval of the nuclear criticality controls is recorded on the FCR.

Operators are trained to follow written, approved procedures which are available in each area. NSE and area management conduct quarterly audits of each operating area to ensure that procedures are followed and that procedures are adequate to ensure safety.

b. Scrap Recovery (1) Licensee's Nuclear Criticality Safety Controls Combustibles contaminated with enriched uranium are collected in 4-foot cubic boxes and are controlled to an estimated safe mass by

. operating procedure. The loaded boxes are moved to the New Decon Room for final sorting and packaging for long-term outdoor storage. The contents of a box is not measured for sixty days.

Noncombustibles are processed in the same way as combustibles until the inventory is determined. Then the boxes are scheduled for disposal.

The incinerator is operated on a safe batch basis. Uranium with an assumed U-235 enrichment is measured into the system. As ash is removed, the uranium and U-235 content is measured and the system inventory is adjusted accordingly. The incinerator feed conveyor is operated by an AEC which prevents charging the incinerator if the inventory exceeds the batch limit.

The non-favorable geometry tanks for collecting FMO waste streams for feed into UPMP are controlled by concentration control and AECs. The same situation is true for non-favorable geometry tanks between UPMP and liquid waste treatment.

The oxidation area is subject to safe mass and volume controls which are assured by AECs.

8 The dissolution and solvent extraction areas are based on favorable geometry and limited mass controls which are ensured by AECs.

(2) Adequacy of Nuclear Criticality Safety Controls The mass control on solid waste boxes during the FM0 solid waste collection, sorting, and storage during the 60 day isotope grow-in period is based on procedural control. There are no positive controls on batch control during this time; the nuclear safety control program is weak. The solid waste collection boxes in UPMP j do have monitors which are indicative of uranium content.

The AECs in UPMP are monitored in the UPMP control room. The process lab near the control room provides frequent information to the control room operator. The control room operator is promptly aware of the process lab information and/or conditions where AECs require an operator to take action. In other situations, the operator is aware that AECs have shut down the process. The close interaction between the control room operator monitoring the AECs, the frequent input of information from the process lab, and the automatic response of the AECs provide adequate nuclear safety control.

The licensee has a procedure whereby AECs in UPMP cannot be changed without NSE review and approval. Each change of an AEC is made using the FCR process. Following review and approval by NSE, a preoperational audit is performed to assure that indicated AEC response in the control room actually takes place in the UPMP process area.

The team was.shown an extensive preoperational audit which was to be performed following upgrade of the incinerator controls, including AECs. The NSE individual who had been involved in the >

incinerator modifications was scheduled to participate in the audit. The team also saw indication of other preoperational audits in UPMP following minor FCR approvals.

(3) Maintenance and Surveillance

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Within UPMP, an annual surveillance program is conducted to verify that the AECs are performing as designed and controlled. The program is new because UPMP has just recently become operational.

! c. Waste Treatment Area (1) Licensee's Nuclear Criticality Controls Liquid is collected in nonfavorable geometry tanks and then, based j

on the uranium concentration, processed through final treatment in safe batch quantities. Uranium solids from liquid waste treatment

9 are collected in 5 gallon containers and treated as scrap or waste, depending on the uranium content.

(2) Adequacy of Nuclear Criticality Safety Controls NSE has done some dynamic analyses for UPMP to determine the time that some of the UPMP process could be out of control before a minimum critical mass could be accumulated. While this dynamic analysis is subject to a variety of basic assumptions, it does show that considerable time is available for the process lab in UPMP to detect a significant process upset.

The collection of uranium solids in 5 gallon containers is based on a combination of favorable geometry containers and safe wet masses of uranium. Concentration controls, which are supported by safety controls in FM0 and UPMP are adequate,

d. Hydrogen Sintering Furnace Area No review of this area was performed. All low-enriched uranium is in ceramic form and processed in a favorable geometry (slab) configuration. Process equipment is designed to keep the ceramic material in this geometry. The process is normally d ry. The criticality accident potential, compared to the other areas described above, is quite low. Explosions and fires can be postulated.

Explosions could possibly cause the slab geometry to be lost but this accident situation would tend to disperse uranium in the area.

Moderation was assumed to be present in establishing the slab geometry so that fire-suppression water should not affect nuclear safety.

e. Summary of Nuclear Criticality Safety Findings (1) Management Controls The NSE group is essentially independent of all production operations. The size of NSE staff allows qualified individuals to specialize in different areas of the facility.

The FCR process requires process engineering or production

, engineering to provide the information that is needed for NSE to perform the nuclear criticality safety analyses. When the nuclear safety controls have been identified by NSE, the Area Manager signs the FCR to show that he approves of the controls for his area of responsibility. These nuclear safety controls are then provided to the operating staff in the form of written procedures

. which are also approved by the area manager and NSE.

1 The nuclear criticality safety evaluations are very detailed and well documented. Another individual can review the document for auditing or as the basis for processing an FCR for the process of a later date. The independent review process was evident because

10-changes in the evaluation and conclusions were noted on the FCRs occasionally.

The quarterly audit program involves a NSE representative and an l area management representative. This dual audit demonstrates plant management concern. The detailed audits following a FCR approval or prior to new plant startup are very extensive. The detailed audit plan is approved by process engineering and NSE and is conducted by both groups. This is particularly effective where AECs are involved.

Area management can make changes without the FCR process if the changes does not impact on nuclear criticality safety. As a bar.kup, however, the changed written procedure must be approved by NSE.

(2) Weaknesses and areas for improvement in the nuclear criticality safety program Based on the above inspection findings, the following program weakness was identified and warrant licensee attention:

- Combustible and noncombustible wastes, contaminated with enriched uranium, are collected in 4-foot cubic boxes, processed in the New Decon Room, and stored for 60 days before the uranium content is measured. During this period of time, safe mass control is based on operator judgement.

Existance of positive control on this material was not apparent. The team discussed with licensee representatives i the establishment of positive nuclear criticality controls for the collection and processing of solid wastes. In the event the controls are not precise, consideration should be given to immediate incineration to eliminate the sixty day accumulation of such boxes of combustible material (IFI i 86-22-05).

The following nuclear criticality safety items should be considered for improvement:

- One recently transferred individual was not familiar with the PRODS for his new area. Since this individual is a backup supervisor, the personnel transfer program should ensure personnel training (IFI 86-22-06).

3 The UPMP area should have the maximum enrichment allowed in UPMP established as an AEC (IFI 86-22-07).

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7. Fire Protection / Prevention Program NRC regulations do not presently establish fire protection requirements for nuclear fuel fabrication facilities. Consequently, the applicable portions of the following Nuclear Industry Fire Protection Guidelines and the National Industry Fire Protection Associated (NFPA) fire codes were utilized to perform the assessment of the licensee's existing overall fire protection / prevention program:

" International Guidelines for Fire Protection at Nuclear Installations including Nuclear Fuel Plants, Nuclear Fuel Stores, Teaching Reactors and Research Establishments", 1978 Edition American National Standard Institute (ANSI) N655-1985, " Fire Protection for LWR Fuel Fabrication Facilities", dated April 2,1985.

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NUREG 0800, Standard Review Plan 9.5.1 " Guidelines for Fire Protection for Nuclear Power Plants", Revision 2, July 1981 The team evaluated the fire potential in the chemical conversion, scrap recovery, waste treatment and hydrogen sintering furnace areas, assessed the adequacy of the administrative fire prevention control procedures, assessed the adequacy of the fire protection system maintenance and surveillance program, evaluated the potential for a nuclear criticality safety accident or a major release of radioactive material which might result in the event of a fire or explosion, and assessed the licensee's response capabilities to mitigate fire conditions.

a. Assessment of Administrative Control Procedures The team reviewed the following fire prevention / administrative procedures: .

Procedure No. Title Practice and Procedure 40-3, Controlling Non-Essential Materials Revision 5, dated February 4, in Controlled Areas 1986 Safety Manual Item 501, Storage and Handling of Combustible Revision dated April 1, 1979 and Flammable Liquids Safety Manual Item III, Administrative Inspections Safety Revision dated September 1, 1980 and Fire Protection Safety Manual Item 503, Cutting and Welding Permit Procedure Revision dated April 1, 1979 Based on the team's review of the licensee's Practice and Procedure 40-3, it appears that sufficient administrative controls are being

12 imposed on transient combustible fire loads in the chemical conversion, scrap recovery, waste treatment, and furnace areas.

However, this procedure does not restrict the use of non-fire retardant wood in process related areas. During the plant walkdown non-fire retardant treated wood was identified in the UF6 vaporization and UPMP areas. The failure to control the use of non-fire retardant wood in uranium process areas is identified as an area needing improvement (IFI 86-22-08).

Safety Manual Procedure, Item 501, Storage and Handling of Combustible and Flammable Liquids, appears to impose the appropriate administrative controls. Safety cans are used to store and dispense flammable / combustible liquids used inside buildings and closed containers and piping systems, which appears to comply with NFPA 30.

Safety Manual Procedure, Item III, Administrative Inspections Safety and Fire Protection requires routine housekeeping / fire prevention inspections to be conducted. However, the frequency of these inspections are not specifically identified in this procedure. The procedure allows the manager of industrial safety to establish the time and date of these inspections. These inspections should be conducted by an individual who is trained to identify potential fire hazards.

The failure to establish an adequate fire prevention inspection program is identified as an area needing improvement (IFI 86-22-09).

Safety Manual Procedure Item 503, Cutting and Welding Procedure, appears to be adequate with respect to the controlling the fire risk associated with welding, grinding and/or cutting, except for fire watch training and pre-work inspections. This procedure required cutting and/or grinding operations to be authorized by an appropriate permit.

It also ensures that combustibles have been moved at least 35 feet away l from welding operations and a fire watch posted with the applicable l type of fire extinguisher for the duration of the work and for 30 l

minutes thereafter. However, prior to initiating the welding process,

' the loss prevention department does not conduct a pre-work area j inspection to verify that the welding, cutting and/or grinding operations are in compliance with the procedural administrative controls and that the appropriate loss prevention measures are being fully implemented. Loss prevention inspection of welding, cutting

( and/or grinding operations is an area identified as needing improvement l

i (IFI 86-22-10).

l In addition, the licensee does not have an established fire watch l training program (initial and requalification) which provides training

associated with welding, cutting and/or grinding fire hazard l recognition, and the selection, use and handling of portable fire

! extinguishers. The failure to properly train personnel concerning welding, cutting and grinding fire watch responsibilities is an area j

identified as needing improvement (IFI 86-22-11).

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b. Assessment of the Licensee's Organization (1) Site Personnel Fire Prevention / Control Training The licensee does not have an established site-wide fire prevention / control training program which provides instruction to site and contractor personnel on: reporting a fire; actions required when they hear a fire alarm; selection, use and handling of fire extinguishers; using combustibles and in particular, the requirements governing the use of such materials and the actions necessary in the event of a combustible liquid spill or gas release / leaks. It should be noted that the licensee's Process Requirements and Operator Document (Prod) 101.04, "UPMP Facility Waste Handling Area 100 and 200, dated September 26, 1985, Section 6.2 requires plant personnel to know how to turn in a fire alarm and attempt fire extinguishment with the appropriate fire extinguisher. However, this procedural item may not be effectively implemented since the licensee does not have an established site personnel fire prevention / control training program. The failure to provide and implement an adequate site personnel fire prevention / control training program is identified as a program weakness and warrants licensee attention (IFI 86-22-12).

(2) Site Fire Prevention / Control Personnel Qualifications and Responsibilities The licensee has not properly established the qualifications or the responsibilities of site fire prevention / control (loss prevention) personnel. The fire prevention specialist should be

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at a level in the organization which permits communications with persons in direct charge of production, engineering, health and safety and other staff units.

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The fire prevention specialist's qualifications should be consistent with the requirements of the position. Therefore, the following is considered to be appropriate qualifications for the fire prevention specialist:

j An engineering degree or equivalent experience Fire protection / prevention engineering experience j

Successful performance of responsibility in fire protection l

and prevention programs l

The fire protection specialist should be responsible for l establishing a fire protection and prevention program which as a i

j minimum should include the following:

Interpretations of applicable codes, regulations and standards l

14 i

Engineering Design Review, including changes of process and material selection Inspection of facility and equipment for fire hazards Hot work (welding, cutting and grinding) permit program Fire protection equipment inspection testing and maintenance Insurance company relationships where applicable Fire brigade organization and training including interface with local fire departments to ensure equipment compatibility Fire damage investigation and reports Recovery planning for minimizing effects of fire damage Notification of protection impairment Emergency fire pre plan procedures Tne lack of establishment of qualifications and responsibilities for site fire prevention / control (loss prevention) personnel is considered a program weakness and warrants licensee attention (IFI 86-22-13).

c. Inspection and Maintenance Program The team reviewed the licensee's safety manual procedure Item 500, Inspection and Correction of Portable Fire and Emergency Equipment, Plant Fire Main and Post Indicator Valve Systems, Revision March 1, 1982, to determine if the various tests outlined and inspection instructions followed General Industry Fire Protection Practices and the guidelines of the NFPA fire codes. Based on this review it appears that the fire pump, the fire detection devices and the halon I suppression system in the UPMP control room, yard mains, hydrants and valves, automatic sprinkler systems, hose stations and hose, and fire walls are not being adequately tested and maintained in accordance with the NFPA fire codes and the manufacturer's recommendations.

The fire detection system in the UPMP computer room actuates the halon suupression system located in this room. There is presently no sensitivity testing, periodic detector cleaning or actuation testing l

being conducted. In addition, there is no periodic supervision circuit testing being conducted. With respect to the halon system, the

! licensee presently does not have an established maintenance and testing program for this system; therefore, the actuation circuit is not periodically tested, the halon cylinders are not pressure checked or weighted and the halon discharge piping and nozzle are not visually l inspected for damage and/or obstructions.

i

- _ _ , , - - , . - , - ~ . , _ _ _ - . - -

15 The diesel fire pump is periodically start tested on a weekly basis.

However, the licensee does not have an established fire pump maintenance and annual test program; therefore, the licensee does not on an annual basis conduct a flow test which duplicate the performance flow curve for the pump. In addition, the licensee has no established test, inspection and/or maintenance program for the: fire pump suction strainer, pressure relief valve, fire pump packing, pump pressure gauges, and the diesel engine driver and fuel system. The licensee also does not have an established inspection and maintenance program which periodically verifies the capacity of the water supply in the concrete fire pond and the sediment level in the bottom of the pond.

The licensee currently has no program which performs periodic fire hydrant maintenance such as inspecting the operating nut packing, verifying the barrel drain is properly working, cycling the foot valve and lubricating the hose connections. In addition, the licensee does not have an established program which periodically flushes the under ground fire main and flow tests the fire hydrants.

The position (open) of the outside stem and yoke (OS&Y) valves which isolate the main water supply to the various plant sprinkler systems are periodically being verified by the licensee. This appears to be the only sprinkler maintenance that the licensee is conducting. The licensee does not have an established maintenance, inspection or test program which performs sprinkler system main drain and inspector test connection flow tests, inspection of sprinkler heads for obstructions, corrosion and/or mechanical damage, and maintenance of OS&Y and sprinkler alarm and trim valves.

With respect to hose stations inside the plant it appears that the licensee has no established maintenance, inspection and test program which requires the hose angle valve to be cycled periodically, i hydrostatic testing of the fire hose, inspection of nozzles, hose coupling and hose for damage and flow testing of the various hose

( stations.

I i In addition, the licensee's fire protection program does not have an

! inspection and maintenance program for fire walls and fire resistive materials which have been applied to building structural steel.

l Based on the above findings, the licensee's fire protection system l maintenance, testing and inspection program appears deficient.

Shortcomings in the program to assure the overall operability of the fire detection, suppression and control systems is considered a program weakness and warrants licensee attention (IFI 86-22-14).

It should be noted that the inspector did find the licensee's fire extinguisher maintenance and inspection program to be adequate.

16

d. Site Emergency Response Team (Fire Brigade)

(1) Fire Brigade Organization The fire brigade consists of 29 members of which 21 members are on production shifts A through D.

The licensee in their Plant Emergency Organization - Fire Brigade Training Manual issued May 8, 1971, indicated that each production shift will have a minimum of seven emergency response team (fire brigade) members; however, on October 8,1986, the "B" shift had only four emergency response team members. The failure to adequately maintain the minimum emergency response team (fire brigade) members on each production shift is identified as an area needing improvement (IFI 86-22-15).

It should be noted that for power reactors that a minimum five member fire brigade is required to be assigned to each shift.

With regard to the brigade assignment at a fuel facility, a minimum five member brigade would be adequate. The brigade should be structured in such a manner that the brigade team leader and two other members have sufficient training or knowledge of the plant process related systems to understand the effects of fire and fire suppressants on nuclear criticality safety in the fuel manufacturing process.

(2) Emergency Response Team (Fire Brigade) Medical Qualifications The team reviewed the annual medical reviews for 12 emergency response team (fire brigade) members. The annual medical review consists of a vital respiratory capacity examination. This form of medical examination appears to be lacking with respect to determining the physical condition of fire brigade members when subjected to stressful situations which can be experienced as a result of fire fighting activities. The medical examination for fire brigade members should consider the physical stress of routine firefighting exercises which are placed on the cardial system. The failure of the licensee's medical examinations for emergency response team (fire brigade) members to evaluate cardiac function is identified as an area needing improvement (IFI 86-22-16).

It should be noted that the examinations being conducted by the medical department were being performed on an annual basis which is in accordance with the commitments made in the licensee's Safety Manual Item 504, Fire Prevention and Emergency Response Team, Revision July 3, 1979.

17 I (3) Emergency Response Team (Fire Brigade) Training Program The team reviewed the training records for two brigade leaders and ten brigade members for the 1985 calendar year. The licensee's Safety Manual Procedure Item 504, Fire Prevention and Emergency Response Team, Revision July 3,1979, requires quarterly training for the emergency response team (fire brigade) members. It should be noted that the quarterly training sessions are being conducted; however, the licensee does not provide makeup training for those members who are absent from the scheduled training session nor do they provide an initial training program for new fire brigade members prior to assigning them to the brigade. This is substantiated by the fact that the training records for 2 out of the 12 fire brigade members sampled indicated that they did not complete the quarterly trainirg requirements and 3 out of 12 fire brigade members sampled were assigned to the fire brigade and had no training at all.

The team requested to review the licensee's initial fire brigade training and quarterly training programs in order to verify that the lesson plans for these programs implemented the following criteria:

i Indoctrination of the plant fire fighting plan with specific identification of each individual's responsibilities.

- Identification of the type and location of fire hazards and associated types of fires that could occur in the plant.

- The toxic and corrosive characteristics of expected products of combustion.

- Identification of the location of fire fighting equipment for each fire area and familiarization with the layout of the plant, including access and egress routes to each area.

The proper use of available fire fighting equipment and the correct method of fighting each type of fire. The types of fires should include fires in energized electrical equipment, fires in cables and cable trays, hydrogen fires, fires involving flammable and combustible liquids or hazardous i

process chemicals, fires resulting from construction or modifications (welding).

The proper use of communication, lighting, ventilation and

, emergency breathing equipment.

The proper method for fighting fires inside buildings and confined spaces.

k 4

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18 The direction and coordination of the fire fighting activities (fire brigade leaders only).

Detailed review of fire fighting strategies and procedures.

Review of the latest plant modifications and corresponding changes in fire fighting plans.

The licensee indicated that there was not an established initial or quarterly fire brigade training program. The licensee's staff indicated that the quarterly training sessions were based on the fire fighting methods and practices documented by the International Fire Service Training Associations's (IFSTA)

Manual 200, " Essentials of Firefighting." It appears that the present licensee's emergency response team (fire brigade) training program is very general and not based on potential site specific fire hazards.

In addition, the licensee does not require the fire brigade to participate in an annual structural fire fighting practice session. These practice sessions should demonstrate the proper methods of fighting the various types of fires which could occur in a nuclear fuel fabrication facility. These practice sessions should provide brigade members with actual hands on experience in fire extinguishment and the use of self contained breathing apparatus under strenuous fire conditions. These practice sessions should be conducted at a state certified fire academy, under the supervision of state certified fire service instructors.

Based on the above findings, weaknesses were identified in the licensee's fire brigade training program. The weakness which are summarized below warrants licensee attention (IFI 86-22-17):

Provide initial fire brigade training to individuals prior to assigning them to the fire brigade.

Develop and implement site specific fire brigade training.

Conduct fire brigade training as scheduled.

(4) Fire Brigade Fire Emergency Plans (Fire Fighting Strategies)

The team requested to review the licensee's fire emergency plans for the various fuel fabrication process areas. The licensee indicated that they had not developed fire emergency plans for the process areas. This finding related to failure to develop fire emergency plans which provide fire fighting guidance to the fire brigade for the various process areas is identified as an area needing improvement (IFI 86-22-18).

1

__ _ ____________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___.J

19 Under complex fire fighting conditions, such as those which could be experienced at the licensee's facility, the fire emergency plan provides a fire fighting strategy which the fire brigade leader can relate to in order to mitigate the pending fire condition.

The fire emergency plans for the various fuel fabrication process areas as a minimum should address the following:

Fire hazards in the areas Extinguishing agents to be used Direction of attack Systems to be managed to reduce loss Heat sensitive systems Fire brigade specific duties Smoke control capabilities Instructions for process production control and isolation Criticality concerns (5) Emergency Response Team (Fire Brigade) Drill Exercise During this assessment, the team witnessed an unannounced fire brigade drill. The scenario was a fire in the air compressor room. The apparent fire condition was caused by a compressor motor. The licensee's staf f utilized a smoke bomb in the room to create authenticity.

The emergency response team (fire brigade) responded to the pending fire emergency. Three brigade members in self contained breathing apparatus and no turnout gear made entry into the fire room and extinguished the fire with CO2 type fire extinguishers.

Based on the team's observations, the following discrepancies were noted which could affect the overall ability of the licensee's emergency response team (fire brigade) to mitigate an actual fire condition:

The fire brigade was not protected by personnel protective (fire fighter's turnout gear) clothing.

The fire brigade members utilizing the self contained breathing apparatus experienced donning problems.

No firefighting hose lines were deployed and used as back-up.

The fire brigade members entering the fire room did not follow proper fire room entry techniques.

The fire brigade did not check for fire extension.

The fire brigade did not establish mechanical smoke control / removal measures.

20 The fire brigade did not initiate fire victim search and rescue / technique during fire fighting operations.

No fire emergency plans were developed to assist in decision making during fire fighting operations.

Based on the above findings, failure of the fire brigade to utilize proper manual firefighting methods is identified as a program weakness and warrants licensee attention (IFI 86-22-19).

The team noted that the discrepancies identified above appear to be attributed to the inadequacy of the emergency response team fire brigade training program.

The team also noted that the licensee does not have an established fire drill implementation program which assures the following:

Conducting drills at regular intervals, not to exceed 3 [

months for each fire brigade shift.

~

Participation by each brigade member in at least two (2) drills.

Participation by each fire brigade shift in at least one unannounced drill.

Participation by each fire brigade shift in at at least one drill held on a back shift.

P~ replanning of all drills.

Critiquing of drills.

Repeating of unsatisfactory drills within 30 days.

Based on the above, failure to conduct fire drills in a consistent manner as established by nuclear fire protection industry practice is identified as a program weakness and warrants licensee attention (IFI 86-22-20).

(6) Emergency Response Team (Fire Brigade) Manual Fire Fighting Equipment The manual fire fighting equipment for the plant is stored in an emergency response van type vehicle and consists of two dry chemical, one metal, two CO2 and two pressurized water fire extinguishers, three sets of self contained breathing apparatus (SCBA), two complete sets of turnout clothing, 200 feet of 2h-inch hose, 350 feet of ih-inch hose, nozzles, hose adapters and miscellaneous forcible entry tools. The team performed an inspection of this equipment and noted that the firefighting

21 equipment other than SCBA and the fire extinguishers was antiquated and not adequate to handle all potential fire hazards / conditions which could occur on site.

In addition, the quantity of the turnout gear is not adequate to protect the responding fire brigade. =The current turnout gear is cotton duck material which is considered to be flammable when exposed to confined structural fire fighting conditions. Based on the above findings, these fire brigade equipment discrepancies are considered as a program weakness and warrants licensee attention (IFI 86-22-21).

e. Inspection of Fire Protection Equipment The team performed an evaluation of the fixed fire protection features provided to mitigate a fire's consequences against the combustible loading of the areas under evaluation.

The majority of the plant production areas in the fuel fabrication facilities are protected by automatic sprinklers, except for those areas where water can cause a criticality concern (i.e., stacker, blender warehouse, dry powder warehouse). Based on the team's evaluation of the licensee's overall fire protection program, the likelihood of an uncontrolled fire in the plant areas protected by the sprinkler systems is considered to be probable. This is due to the various sprinkler and hose station design discrepancies, weak fire protection system test, maintenance and inspection program and the

! potential inadequacy of the licensee's emergency response team (fire brigade) with respect to mitigating initial fire conditions.

Currently, the licensee does not have any outside manual fire protection capabilities which would allow a minimum of 500 gpm of water to be applied by the fire brigade to either protect the UF6 cylinders or prevent a propane tank bleve (boiling liquid expanding vapor explosion). In addition, there are no fire hydrants and outside fire

, protection capabilities provided for the bulk combustible waste box storage area. Presently, there are approximately 3000 combustible waste storage boxes in the yard storage area waiting to be incinerated.

, These boxes are susceptible to an external exposure fire which could be l caused by a brush or forest fire. If these boxes were to become i involved in a fire a potential radioactive release could occur. Based on the above findings, failure to fully implement a comprehensive fire protection program which will minimize the potential fire risk to l radioactive materials stored outdoors is an area needing improvement

! (IFI 86-22-22).

i l During the plant tour, the team noted certain fire protection system discrepancies which are considered as program weaknesses and warrant licensee attention:

I

_ - - _ _ _ _ _ _ _ _ _ _ _ . . _ _. _ _ _ _ , . . , _ . . _ . m _

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22 The current fire water supply, pumping and distribution system does not have the capability to allow the offsite fire department to draft water from either the pond or the elevated fire water storage tank and supply the sprinklers in the event of a fire pump failure (IFI 86-22-23).

In several plant locations associated with FM0 and FM0X buildings, sprinkler heads were obstructed by heating ventilation and air conditioning (HVAC) duct work and building structural steel.

(IFI 86-22-24). 0 Sprinkler protection is not installed under the mezzanine areas {

near the calcination furnaces (IFI 86-22-25).

Sprinkler heads over the GEC0 process mezzanine require heat collection devices to be installed. The lower sprinkler line is installed approximately 10 feet below the ceiling (IFI 86-22-26). .

The 11/2-inch fire hose stations installed in the FM0 and FM0X buildings do not appear to be designed in accordance with NFPA criteria. Typically, one-inch piping off the sprinkler system is utilized by the existing design to supply a 1 1/2-inch hose station (IFI 86-22-27).

This design due to excessive friction loss may be inadequate with respect to supporting an effective manual fire fighting hose stream (IFI 86-22-28).

The discharge line and grounding cable associated with the hydrogen truck trailer facility located on the south side of the FM0 building are deteriorated. The deteriorated grounding cable could cause a static electricity induced fire as a result of process use/ discharge of hydrogen (IFI 86-22-29).

8. Chemical Process Safety

a. General Housekeeping conditions were observed to be generally adequate. Some light dusting of equipment and grounds was noted in the waste treatment area. Since this was an ouside area, this would not likely present a dusting hazard to employees.

The chemicals handled at the facility ranged from very low toxicity to extremely high. The most highly toxic materials seen at the plant were uranium hexafluoride, UF6, and hydrogen peroxide, H202. The strongest acid in use at the plant was hydrofluoric acid, HF. Bulk storage and usage of the following chemicals was found at the site:

23 Calcium Hydroxide (CaOH)

Ammonia (NH3)

Hydrofluoric Acid (HF)

Hydrogen Peroxide (H202)

Nitric Acid (HNO3)

Hydrochloric Acid (hcl)

Sodium Hydroxide (NaOH)

Hydrogen (H2)

Sulfuric Acid (H2SO4)

Oxygen (02)

The hazardous chemicals handled onsite included such acids as hcl and H2SO4, and bases such as Ca0H and NaOH. These compounds are by their nature dangerous if mixed due to the heat generated from the acid-base reaction, which can be quite violent. Also, these common industrial materials are quite corrosive and can destroy plant equipment if not properly designed and handled, causing leaks and possible chemical burns to the workers. Releases of these materials can also cause environmental damage. These compounds were found throughout the site to be handled in a safe manner and in proper (usually stainless steel or better) equipment. In some cases, anhydrous (extremely dry) acids or bases can be stored or handled in mild steel, and where this was done at the facility it was done using acceptable practices.

The storage of these acids and bases was generally in above ground tanks. Acids and bases were separated. The use of dikes and sumps to catch leaks and to prevent releases to the environment were noted.

Piping was mainly welded stainless steel, and followed standard industrial ' practice or better in all cases observed.

The wastes at the facility were segregated according to the content of the waste stream (nitrates or fluorides). Both acids and bases were mixed into these streams, with the streams treated to alter the pH of the material at various points.

The backflow of process materials and mixtures into the various chemical feed lines is a problem which can effect even the steam or water feed systems. The licensee is very aware of this issue because of the potential for nuclear criticality. In all cases observed, some type of backflow prevention was built into each chemical service, even in situations where uranium was not present.

With nuclear criticality safety in mind, the licensee has undertaken both formal probabilistic risk assessments and other non probabilistic fault tree analyses of the plant from both uranium and chemical standpoints. Since formal risk assessment may show only that safety has been looked at in the past and the lessons learned may not have been permanently internalized, some audits should be performed at least annually to insure that the engineering and management staffs are still giving attention to chemical safety issues. There was no indication

24 1 when talking to either safety, management, or operations personnel that there was any such deterioration in chemical safety. The entire safety professional staff appeared to be two' individuals, but they appeared to have an extended network of people within each operating area. These people knew the production procedures and appear to have some influence 4 on them, since the standard operating procedures contained safety cautions and the reasons for them. Operations personnel at the lowest levels were able to speak knowledgeably of these cautions' and on chemical safety in general, thus reflecting adequate training, in this area. Management at all levels was also able to speak cohesively on these issues as well.

Based on the above findings, this facet of the program appears

< adequate; however, the following item should be considered for improvement:

Conduct annual audits of the chemical safety program

, (IFI 86-22-30).

b. Audit of S0Ps for Chemical Safety The Standard Operating Procedures (S0P) themselves were apparently i updated or at least reviewed on a periodic basis, at least annually.

The entire set of volumes was several hundred pages. Based on their weatherbeaten appearance the procedures showed considerable use. The SOPS reflected the existing equipment in the facility, which indicates some effort at keeping them current.

c. Chemical Handling Safety 1 One chemical handling safety issue was identified by the team during an evaluation of the. plant systems. This involved lack of attention to posted procedural details associated with the safety lockout procedure.

The safety lockout procedure called for the supervisor to lockout a i piece of equipment about to be serviced, such that the equipment could not be started until the lockout was reversed. Further, the supervisor  !

was to tag the equipment with a danger indication and the reason for the lockout. While on the inspection of the production facility,

several of these lockout tags were evident. These were always on equipment which indeed was not in service; however, at one point it was

{

observed that a maintenance team was working on a pump where the i impeller had been removed for maintenance. An operator was with the maintenance crew doing the work, and indicated he would not leave that i post until the maintenance was complete. There was no evidence of any lockout tags, and the supervisor indicated that he was not involved in

the lockout of this particular pump. Thus the safety lockout procedure

in the S0P was not being followed. Since the operator appeared i knowledgeable and demonstrated that he was in control, there was no

, immediate danger associated with not following the posted procedure.

j This failure to give attention to safety precautions / controls is l

l

25 identified as a program weakness and warrants licensee attention (IFI 86-22-31).

9. Operations Engineering

a. Calibration Program The calibration program for scales and balances i s described in Practices and Procedures (P/P) number 70-25, Scales and Balance Program. A separate program, P/P number 70-23, Instrumentation and Controls Program, is provided for calibration of process and laboratory instrumentation. The following items were observed:

QEIP B-40.1 requires non accountability balances to be calibrated quarterly and scales to be calibrated annually. Also, a certification of standard weights are required biennially. The inspector verified that a current certificate, No. 000733, had been issued by the North Carolina Department of Agriculture Consumer Standard Division for the 1000 lb. weights serial Nos. 748 and 749. These 1000 lb. weights are used once per day in the vaporization area per Quality Control Operator Requirements of PROD 10.05 to verify calibration of the scale used to weigh the UF6 cylinders.

Scheduling of scale and balance calibrations has been computerized. Other items such as monthly visual inspections of standard weights are also computerized. One of the disadvantages of the computer program, however, is that for each entry only one frequency can be programmed. Thus items which have two different frequencies associated with them have only one in the computer system. For example, standard weights require a monthly inspection and a biennial certification. The certification is currently being tracked manually on log sheets. The inspector discussed with the licensee the possible assignment of a slightly modified serial number which would allow use of the computer scheduling system. The cognizant supervisor agreed to look at possible methods to use the computer program to schedule the certificates.

Administrative Routine 340-CHME-78-238, Instrumentation and Controls Calibration Procedure requires a calibration signal to the primary element in the instrumentation loop and check of each component of the loop. This is normally accomplished by use of vendor manuals in lieu of written instructions. A data sheet is

- supplied for each instrument loop.

- Process instrumentation in the UPMP, scrap recovery facility, has been classified as essential and non-essential. P/P 70-23 defines essential instrumentation and controls as "Those instruments and controls used to measure or control parameters which involve product quality, nuclear safety, nuclear materials management,

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• 26 environmental protection, or other parameters which, if out of calibration, could have an adverse impact on the above parameters which may not be detected by normal quality checks." This same concept has not been applied to the older facilities such as process lines in FM0 and FM0X. In other words, instrumentation used in the ADU or GECO lines to prevent process upsets or

! industrial type (non-criticality) accidents are not classified as essential instruments or controls. For example, instrumentation installed in the vaporization area to cut off the UF6 cylinder heaters when an over temperature or pressure condition is sensed is not considered as essential. The failure to classify certain important controls and equipment in FM0 and FM0X as essential equipment may have an impact on plant safety and quality. This matter i s considered a program weakness and warrants licensee attention (IFI 86-22-32).

A method exists to trace calibration equipment back to a certified national standard. The instrument used for calibration is listed on each Loop Calibration Data Sheet. The calibration date and instrumentation used is later transferred to a computer data base.

The team verified that the instrument, number G9W4828, used to calibrate the vaporizer IA and 18 cylinder pressure limiter on October 4,1986, is traceable to a standard which has a current certificate.

Instrumentation associated with UPMP is in the process of being turned over to the manufacturing department instrumentation and contro1 (I&C) group.

The I&C group maintains a computer scheduling system for the r

,. process instruments and controls assigned to it. The group has

! primary responsibility for implementation of P/P 70-23. The team j was informed that there have been three different computer systems (programs) for scheduling calibration within the last five years.

In fact, it appears that some data has been incorrectly entered i into the current program database. For example, the due date for

! instrumentation calibration in 1985 was recorded as 1986 instead of 1985. The cognizant supervisor indicated that the data was available to correct the database and that action would be taken l, on this matter.

f The entry of the calibration instrument into the computer data l base allows easy determination of the process instrumentation which was calibrated by an instrument which is later found out of calibration. No procedure currently requires this to be done. If i a non-conformance is issued on an instrument, the significance of I this is required to be evaluated for necessary action. The team

, was shown only five non-conformances that had ever been issued l concerning process instrumentation, none of which addressed a l

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4 27 calibration. The supervisor identified that this condition had occurred on occasion.

Procedure P/P 70-23 item 4.5.3.13 states "A calibration due date may be extended once for up to 15 days for unusual circumstances.

In these cases, the extension period shall be documented on a QIE Non-Conformance Report under Section B-2, ' Action to be Taken',

and approved by the appropriate ... subsection manager." When the team requested to review this documentation, the cognizant supervisor said that this was not their practice to issue a non-conformance or obtain the subsection manager's approval when an extension is granted. The normally used grace period is 30 days. The need to follow procedural requirements was discussed with the subsection manager. The licensee agreed to conduct an evaluation of the procedure requirement and its implementation.

There is no procedure requirement to review the previous history of an instrument found out of calibration; thus, the need to increase the calibration frequency may not be noticed. In fact, because only the last calibration date has been entered into the present computer program, it is difficult to establish the calibration history of an instrument loop.

Record keeping inconsistencies were noted. For example, a vaporizer cylinder pressure limiter, loop F1V1002, was shown by the computer database as being last calibrated on December 11, 1983, but the last data sheet was dated September 24, 1984. The team was shown a non-scheduled calibration which was performed immediately before this inspection, e.g., on October 4, 1986. The team also was informed that calibration of this instrument as well

as the other pressure limiters and temperature limiters on the vaporizer cylinders was performed in May 1986. This was a specially requested calibration by management. Data sheets were apparently not kept on these calibrations. Some records of these limiters loops show that the calibration came due but were not calibrated because equipment for calibration was not available.

In some cases, it appears that no attempt was made to calibrate them until the next due date. However, because of the record

. keeping, it is not possible to definitively determine the exact

! situation.

With the exception of the program weakness noted above the licensee's calibration program is generally adequate; however, the i following area should be considered for improvement:

Modify computer program used for calibration scheduling so that more than one calibration frequency can be programmed (IFI 86-22-33).

l

28 Correct calibration "due date" records (IFI 86-22-34).

Evaluate the procedural requirements and actual practices concerning extension of calibration "due dates" (IFI 86-22-35).

Improve overall recordkeeping pertaining calibration (IFI 86-22-36).

b. Maintenance Activities Corrective maintenance is performed in accordance with a maintenance work request (MWR). The MWR describes the work to be performed and i provides documentation of work accomplished. A tag and hold procedure is provided to remove equipment from service for personnel safety.

Operating personnel indicated that valves and breakers which are i required to be manipulated to allow individual component maintenance are determined from knowledge of plant and/or plant drawings and are returned to service in a similar manner. A written list of components manipulated is not required. For system maintenance or extended maintenance outages, systems are realigned with the assistance of plant

engineers with special temporary instructions which provide detailed instructions for returning the process lines to service. These temporary instructions are necessary because the normally used production procedures (PRODS) do not contain valve and breaker checklists. The inspector observed that critical valves are identified in the field by a tag giving the valve number and the words critical j valve. Most other valves are not labelled but are referred to in procedures by a noun name which indicates their function. Because of the relative simplicity of the processes and the engineered interlocks designed into plant components, this method of removal and return to

' service appears adequate. Corrective maintenance activities are normally performed by direct use of vendor manuals and drawings as deemed necessary.

i Preventative maintenance (PM) is scheduled by computer and performed using vendor manuals or if necessary specially written procedures. The team examined the PM program for the heating, ventilation and air conditioning (HVAC) systems and the 500 kw diesel generator. The HVAC system is assigned to one plant group and the diesel generator to a 4

different group. The following are observations concerning the HVAC PM program.

A list of 27 possible items to be checked had been established.

Examples of these are checking housekeeping, bearings, dampers / operators, motor-amps / RPM, lubrication, belts / guards, proper control operation and proper fuse size.

Applicable inspection items (from the list of 27) are specified and tracked by a computer program for each work station and unit number.

29 A program is being developed to trend flows , differential pressures, temperature and vibration of major components. A prototype system is in place, full implementation is planned within a year.

- Maintenance performed, both corrective and preventative, is documented on the HVAC Maintenance Labor and Materials Tracking system.

The following items were noted concerning the 500 KW diesel generator.

The 500 KW diesel generator provides emergency power to the incinerator, vaporization, HVAC system, FM0 roof scrubber system, CO2 system and vaporization safety interlocks.

A PM checklist is provided for weekly inspections. It contains seven items which are checked: start /stop controls, coolant level, engine oil level, coolant hoses, services batteries, unusual noise or vibration, and oil or coolant leaks.

Vendor recommended PM (Detroit Diesel Allison Series 92 Operators Manual) are nnt contained in any written procedures or scheduling system. It is not clear what vendor recommendations are being implemented and what the bases is for deviating from them. For example, the vendor recommends an oil change after 150 hours0.00174 days <br />0.0417 hours <br />2.480159e-4 weeks <br />5.7075e-5 months <br />, the current practice, not specified anywhere, is 300 hours0.00347 days <br />0.0833 hours <br />4.960317e-4 weeks <br />1.1415e-4 months <br />. It appears that the scope and frequency of the PM performed is left up to the assigned mechanic.

Inspection of the diesel revealed that the starting battery had low eTectrolyte level, in that 2 of 6 cells appeared to have levels below the plate tops.

Logs of inspections appeared to contain minimal information and did not record all the items that the mechanic indicated that had been performed in the last few months.

- Vendor manuals filing system appeared to be cumbersome and in one instance (out of three requests) the 150 KW diesel generator manual has been misfiled. It was located with the manuals for forkli f ts.

Equipment has been procured to measure equipment vibration.

Development of a base data is planned in the near future.

During several plant tours, the team observed that the equipment appeared to be generally well maintained.

In summary, the PM program appears to be adequate; however, the following item should be considered for improvement:

30 Implement vendor PM recommendations for diesel generators (IFI 86-22-37).

1 Include inspection of electrolyte levels in PM checks and services for batteries (IFI 86-22-38).

Improve log entries pertaining to maintenance performed (IFI 86-22-39).

Improve filing and recordkeeping systems for vendor PM service manuals (IFI 86-22-40).

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c. Surveillance Activities A separate surveillance program does not exist but surveillance type activities have been incorporated to an extent into normal operating procedures (PRODS), maintenance activities or other programs. Examples of these include the following:

PROD 10.05, Vaporization - ADU and GECO, and PROD 10.10, UF6 Cold Trap, requires functionally testing of UF6 detectors by placing an object in the light beam and verifying alarms prior to loading a cylinder into the vaporization chamber. Also, prior to loading a cylinder, each emergency CO2 cooling system spray valve is tested by actuating the motor control center ON/0FF switch and verifying visually the spray of CO2 liquid.

- PRODS 30.10 and 30.40, for the operation of the sintering furnaces ,

, for ADU and GEC0 require functional testing of the switch over to nitrog'en when loss of disassociated ammonia (DA), the source of hydrogen gas, is detected. This is accomplished by momentarily interrupting the supply by bleed off to the supply valve solenoid and verifying that the low DA pressure switch actuates and the

' flowrate of nitrogen increases from zero to greater than 19 CFM.

An operator successfully demonstrated this test for the team.

This test is required monthly. Testing to verify that the supply valve will close, e.g., the solenoid receives a signal to bleed off air upon loss of DA, appears not to be done. It should be noted that the most common mode of solenoid failure is failure to change state, which is being tested.

QIEP D110.5, Monthly Maintenance of Batteries for Criticality Warning System and Autocall, requires monthly checks of inside batteries for specific gravity of at least 1.10. Outside batteries are required to be replaced annually. The inspector discussed with the cognizant supervisor that certain items

' normally seen in monthly battery surveillance procedures were not included in QIEP D110.5. These include instructions for correcting specific gravity for temperature, verification of electrolyte level and verification that the trickle charge system is energized.

31 Area walkdown of the HVAC system performed at least once per week includes actuating dampers which have external pilot positioners.

Dampers with valve type actuators such as the emergency exhaust damper in the FM0 vaporization area are being checked on an unspecified but less frequent basis. The cognizant supervisor had the appropriate procedure revised to provide periodic actuation of the emergency exhaust damper.

Recent testing has been performed as part of the modification acceptance testing on some items. For example, in the FM0 vaporization area, the HVAC system ability to align to the emergency recirculation mode when initiated by local emergency push buttons was tested earlier this year. Current plans are to incorporate functional testing of these emergency switches into periodically scheduled procedures.

The 500 KW diesel generator is being operated when the plant is experiencing peak loads. This practice was initiated this year as a method of reducing monthly demand charges and hence operating .

cost. The team was informed of no periodic test program to verify I proper diesel starting and loading upon loss of offsite power.

In addition to expanding the surveillance activities associated with the HVAC system, the team was informed that procedures are to be developed to functionally test devices that secure the heating of UF6 cylinders when high temperatures or pressure is sensed. These devices were tested earlier this year at the recommendation of the review panel which was established to review events at other fuel facilities. The functional testing will most likely be scheduled with or incorporated into the calibration of the sensors.

In general, the team noted that functional testing is not an integral pr.rt of calibration. This differs from the practice associated with the nuclear power industry. For the power industry, technical specifications require functional testing be a part of the calibration of certain instrumentation, in particular that associated with systems i

required to prevent or mitigate an accident. The instruments which sense temperature or pressure of the UF6 cylinders would be analogous to those classed as required to prevent an accident at a power reactor.

l These temperatures and pressure sensors and associated instrumentation i

loops form passive interlocks. A passive interlock is one which is

! separate from the normal control instrumentation loops and whose sole l

purpose is to shutdown equipment or a process when a parameter goes outside its normal range. It appears appropriate that a review should l be conducted to identify other passive interlocks and develop periodic functional testing which is commensurate with their safety function, e.g. , criticality safety, environmental safety, personnel safety and equipment protection. Non passive interlocks include those which l perform a permissive function. These interlocks actively prevent j operation of a process or piece of equipment until certain conditions i are met. The active interlocks include devices which sense l

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32 temperature, pressure, flow and open and close positions. Equipment with active interlocks include the calciners, the sintering furnaces and the GECO reactors. Active interlocks are to a large degree self testing. If they malfunction, it will probably not be possible to start the equipment. The design of the plant equipment is such that many, if not most, active interlocks must change state to provide their permissive. On loss of power, these interlocks would fail such that the permissive is removed and the equipment or process will shutdown.

This combined with other features such as redundant valves which close on loss of power or instrument air provides a defense in depth approach to safety. There afe' cases, however, in which active interlocks may malfunction in a non-conservative manner. For example, a switch which would normally have to close to provide a permissive may fail closed, thereby providing a false permissive condition. This can occur to limit switches as well as to electrical contacts. One of the purposes of surveillance testing is to discover such conditions. As stated above, special emphasis should be placed on passive interlocks; however, an additional degree of confidence in the safe operation of the facility may also be realized by periodically functionally testing active interlocks where practical. For example, interlocks associated with opening of the sintering furnace doors might be tested by challenging the interlocks, e.g., attempting to open the door when a simulated non permissive condition is applied.

Based on the above findings, this area appears adequate; however, the following item should be considered for improvement:

identify passive interlocks and develop a periodic functional testing program (IFI 86-22-41).

identify active interlocks and develop a periodic functional testing program (IFI 86-22-42).

10. Evaluation of Accident Potential 1

a. Fire There is a fire potential at the plant because the ljcensee stores and uses combustible materials and flammable liquids (and gases in their processes. The most significant fire potential is associated with the

, bulk propane storage facility. In the event of a fire involving the propane storage tanks, the UF6 cylinder storage area would be exp6 sed.

i If the propane tanks were to bleve (boiling liquid expanding vapor explosion) a massive fire ball could potentially expose the UF6 cylinders oto a temperature level causing overpressurization and possibly rupture. Currently, the licensee does 'not have fire i protection capabilities to prevent a propane tank bleve or to protect the UF6 cylinders. This particular matter is considered a program weakness and should be evaluated further by the licensee (IFI 86-22-43).

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33 Another fire potential is the 4x4 wooden boxes for storage of waste materials contaminated with uranium which are awaiting incineration to recover the scrap uranium. These boxes are stored in an area on plant property which is vulnerable to a brush or forest fire. The licensee has essentially no fire fighting capability on the storage site other than response capabilities of the local volunteer fire departments.

This would be inadequate protection in the event of a forest fire.

In addition, it appears that minimal fire protection considerations have been provided to mitigate a postulated fire condition trl side the main control room control boards associated with the UF6 vaporization line, and to handle a fire which creates an exposure to the UF6 yard cylinder and combustible waste yard storage areas.

The concern with the control room fire is that shorts, shorts to ground and hot shorts could cause spurious operation of process valves and pumps and cause spurious instrumentation readings which could have an effect on the safe shutdown or control of the UF6 vaporization process.

The licensee has not performed a fire effects analysis for the control room to assure the necessary operator action to mitigate spurious operations and shutdown the UF6 vaporization process. With respect to fire protection, the control room is not protected by sprinklers, and the control boards are not provided with automatic fire / smoke detection capabilities.

The types of fires that could be postulated within the facility buildings would be limited by the quantity of combustible and flammable materials plus protective systems such a sprinklers, fire hoses, and extinguishers provided to mitigate a fire. Fighting a fire at the plant with inadequate equipment may also represent a potential for injury to personnel.

b. Nuclear Criticality Safety i The accident potential for a nuclear criticality accident does exist at the plant because of the quantities of low enriched uranium which are l

processed and stored. With the physical and administrative controls provided to storage and operating conditions, however, the probability of a nuclear criticality accident is very small. Accident potentials for various process areas are assessed below:

(1) Conversion Area l

There is a nuclear criticality accident potential in this area I because enriched uranium solutions and " wet" and " dry" enriched -

uranium compounds are processed in this area. If the uranium solution is not maintained in well-spaced favorable geometry equipment or if the " dry" uranium is allowed to be moderated, nuclear criticality could occur.

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34 (2) , Scrap Recovery Scrap recovery areas include the solid waste collection and sorting areas (Decon Room) in FMO, the outdoor storage pads, counting facility, and the incinerator. In UPMP, areas include the oxidation area, liquid rad waste, liquid fluoride waste, liquid nitrate waste, dissolution and solvent extraction.

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! There is a nuclear criticality accident potential in this area because enriched uranium is accumulated in arrays of boxes where the contents of each box is an estimated safe mass of uranium.

The incinerator is operated on a continuous safe batch operation where the inventory is based on uranium mass input minus the mass output difference. The UPMP is based on combinations of favorable geometry - limited mass operations except that some of the FM0 feed surge tanks and waste collection tanks are large nonfavorable geometry. Also, the UPMP equipment uses favorable geometry control for a specified maximum enrichment or enrichments. Also, the licensee is authorized to possess uranium which is enriched to a higher level than the enrichment authorized in UPMP.

(3) Waste Treatment Area There is a nuclear criticality accident potential in the liquid waste treatment area because some of the low-concentration enriched uranium solutions are collected in large tanks for final treatment and release. The accident potential is minimized, however, by concentration and geometry control,

c. Uranium Hexafluoride Vaporization i

The possibility for a major release of uranium as UO2F2 and HF acid exits because uranium hexafluoride is raised to an elevated temperature to provide for vaporization. The vaporization of uranium hexafluoride, i

l however, is being performed under controlled conditions with control l

and safety mechanisms. In the event of an incident, such controls j serve to: quickly lower the temperature of the material, contain the material within the vaporization bay and treatment systems, and capture the majcrity of the material prior to release through the ventilation system. The probability of this type of accident is considered to be very low in view of the controls to mitigate the consequences.

d. Accident Potential Summary In view of the assessment findings a detailed accident evaluation is warranted by the licensee. This evaluation should focus on likely accident scenarios with an emphasis placed on the administrative and engineered controls necessary to mitigate the consequences of such I

. accidents. This matter is identified as a program weakness and warrants licensee attention (IFI 86-27-44).

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11. Radiological Contingency Plan

a. Scope The purpose of this evaluation was to assess the licensee's capability to respond to an emergency or abnormal condition through implementation of the Radiological Contingency Plan (RCP) and associated procedures.

This evaluation included an examination of emergency facilities and equipment, emergency classification and notification procedures, offsite coordination and capabilities, training, and the administration of the emergency preparedness program.

b. Offsite Agency Coordination and Training The licensee had established a program for integrating offsite organizations into the emergency preparedness program. Updated letters of agreement were in place for the various organizations designated to support the licensee in the event of an emergency and the range of support coverage was adequate. The licensee had also made provisions in its RCP to provide training to these groups in the form of plant tours, lectures, and participation in drills.

The team interviewed representatives of the Wrightsboro and Castle Hayne Volunteer Fire Departments, the New Hanover County Memorial Hospital, New Hanover County Emergency Services, and the New Hanover County Sheriff's Department. Discussions with these groups indicated that they were aware of their responsibilities as set forth in agreement letters, and did not have any significant problems concerning coordination and communications with the plant. These discussions as well as rev'iew of licensee documentation indicated that neither of the fire departments had participated in any onsite drills with the Emergency Response Team. Drill participation has been limited to telephone contact only. This was identified to the licensee as unsatisfactory, in that a drill constitutes interactive responses such that emergency response capability can be developed and maintained.

This failure to provide for the aforementioned drills was identified as a violation of Section 7.2, Table 7.1-7 of the Radiological Contingency Plan. Other aspects of the offsite training and drill program were found to be as set forth in the Plan.

Violation (VIO 86-22-45): Failure to provide for drills with the offsite fire department on an annual basis.

During these interviews, the equipment which had been provided to New Hanover County Memorial Hospital for use in handling contaminated individuals was also inspected. The quantities and types of equipment appeared adequate; however, one problem was noted. Two monitoring instruments in storage at the hospital were found to be out of calibration. It was determined that these instruments were not on the licensee's calibration list (four present in supply; two on maintenance l

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2 list). This problem should be resolved with the hospital to ensure l that properly maintained instrumentation is available for their use.

The findings indicate that the licensee has implemented a program in this area of offsite agency coordination and training as provided for l in the RCP; however, the following item should be considered for improvement:

Resolution of the out of date calibration of radiation monitoring equipment at New Hanover County Memorial Hospital (IFI 86-22-46). 1 The following items in the areas of offsite agency coordination and training taken collectively are considered as a program weakness and warrant licensee attention:

Include a complete description in the RCP of the response role and capabilities of offsite agencies (private and governmental) for responding to an emergency (IFI 86-22-47).

Designate in the RCP with whom the various offsite groups will

! interface during an emergency (IFI 86-22-48).

Include a description in the RCP of the equipment provided to New Hanover County Memorial Hospital, including quantities, instrument ranges, etc., and the frequency with which they will be inventoried and calibrated (IFI 86-22-49).

Specify that the program for training offsite support organizations (Rescue Squads, Sheriff's Department) is to be performed on an annual basis, and ensure that this training describes each specific response role and plant access procedures (IFI 86-22-50).

l l c. Emergency Classification and Notification The classification system used by the licensee consists of several predetermined emergency classes. The levels of emergencies as described are local plant emergency, operational plant emergency, site

, emergency and general emergency. Each level has required notifications to offsite agencies associated with it. Although the licensee has described such a classification system, it does not incorporate the

' standard nomenclature for emergency classifications as applicable for nuclear facilities - Notification of Unusual Event (NOUE), ALERT, SITE AREA EMERGENCY, and GENERAL EMERGENCY. By using the standard classification nomenclature, the licensee can be assured that local, state, and federal organizations will understand the severity of the incident such that they can appropriately activate their response organizations and respond to public inquiries accurately.

_-_ ~ .. - -. . -.

37 In addition, the licensee's classification system is not mutually exclusive with respect to the types of emergencies that could occur k each class. The ambiguity is greatest between the local and operational plant emergencies. The classification scheme should describe detailed accident types with associated action levels as examples for each emergency. The licensee should also consider adding additional occurrences to its scheme which would warrant upgraded attention by on site or offsite groups. Examples of these are: the transportation of a contaminated individual offsite, a transportation accident to which plant personnel would respond; loss of offsite power; and a malfunction of the ventilation system.

For the three highest emergency classes, the licensee specifies the performance of notifications as "immediate" to state, local and federal organizations. It should be clarified that such notifications will be performed within 15 minutes (State and local) and one hour (federal) after emergency declaration. As discussed elsewhere in this report, this action should be performed whether the principal staff has arrived or not. In addition, the 30-day notification for local plant emergency is not appropriate for emergency response purposes. Although the abnormal occurrences in this class are less severe, it is important that such notification be performed in the same time frame as all others.

The team reviewed the licensee's methods for notifying offsite organizations and augmentation personnel. The implementing procedures specified when and how the augmentation personnel would be notified during both normal and off-shift hours. The individuals responsible were aware of the methods used and had the appropriate information available to them. The method for notifying offsite agencies was less

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well defined. Each procedure called for such notification; however, because different individuals performed this function depending on accident type, the details of implementation were not found. No information was provided concerning message content, how messages would be authenticated, or what back-up communications systems were available i

in the event of failed telephone lines. The licensee should develop a l specific notification procedure to include a standard notification message form (characteristic of a fuel facility), the content of which should be coordinated with state and local organizations. Such a message should be tailored to meet the needs of all groups potentially involved.

t The licensee did maintain an emergency call list for contacting those l

persons whose assistance would be required during an emergency. The licensee should provide for a quarterly review and update of this listing to insure that all numbers are correct. The licensee should also include the number for Carolina Power and Light since they are referenced in the procedures as a group to provide assistance.

In general, the licensee's classification procedure is considered a weakness and warrants licensee attention (IFI 86-22-51).

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38 Based on the above findings, the following items should be considered for improvement:

Modify NOUE equivalent class to be notifiable within 15 minutes (state and local) and one hour (federal) of emergency declaration (IFI 86-22-52).

Clarify notification procedures such that "immediate" modification is indicative of 15 minutes (State and local) and I hour (federal)

(IFI 86-22-53).

Develop and implement a standard notification procedure to include standard message form (IFI 86-22-54).

Provide a method for authenticating any emergency message (IFI 86-22-55).

Provide a complete description of the back-up communication systems available for notification to include which offsite agencies can be contacted by each means (IFI 86-22-56).

Provide for a quarterly update of the emergency call listing (IFI 86-22-57).

Include Carolina Power and Light on the emergency call listing (IFI 86-22-58).

d. Emergency Facilities and Equipment This area w~as inspected to ensure that the licensee maintained adequate facilities and equipment for conducting operations during an emergency.

The team toured the Emergency Control Center (ECC), the location from which emergency operations would be conducted. The ECC was equipped with various communications links, survey meters, protective clothing and SCBAs, P&ID drawings, and administrative supplies. For conducting assessment and monitoring activities, the ECC was also equipped with a meteorological parameter display system and a radiation monitoring information console with trending and alarm functions for the various continuous air monitors, stationary air samplers, and criticality monitors. In general, the equipment available in this center was as specified in the RCP, with one exception. The ECC had not yet been supplied with the locations and numbers for the fire boxes in the UPMP facility. In addition, this information had not been incorporated into the emergency procedures.

The licensee's ability to assess emergency situations from the ECC is adequate, in that meteorological information as well as radiation levels can be evaluated. It was discovered during walk-through evaluations, however, that the licensee did not have the ability to

39 perform UF6 dispersion calculations in the ECC. These computer calculations are performed on a plant system called REMTRAC, and there are no terminal capabilities or hardware available for its use in the ECC. Although this capability is available at any plant terminal, the licensee should consider adding this versatility to the ECC. In addition, it was determined that a method was not incorporated into the procedure for converting these dispersion results into an offsite significance, radiological or nonradiological. Although individuals interviewed could perform and develop a hazard assessment, some correlation of results should be incorporated into procedures such that any individual using this program can quickly transmit useful hazard information and protective recommendations to the State. The above statements do not apply for criticality dose assessment, in that a manual method for dose assessment and protective action decision making had been proceduralized.

Communications equipment appeared adequate. Commercial telephones as well as several means of back-up communication were available. These backup systems included a base radio system, a public address system tie-in into the criticality warning system, and a mobile radio telephone located in the Emergency Response Vehicle. Also available for communications between plant personnel, the ECC, and the emergency teams is a system of portable radios. The radios are located in the Security area, adjacent to the ECC, and used routinely by Security personnel. Because this equipment is removed from the other equipment in the ECC, its location should be specified in the RCP and procedures such that it can be easily accessed during an emergency.

The team conducted operability checks on selected equipment in the ECC, and no problems were encountered. The team noted that since all of this equipment was not routinely used, the licensee should perform monthly checks and maintenance on this equipment. In conjunction with these checks, the licensee could also incorporate a communication drill where an emergency message would actually be transmitted. This would ensure that the equipment would be operable, and individuals using it would be trained on its operation in the event of an emergency.

The team made selective examinations of emergency kits onsite, and found them to be inventoried and maintained. Observation, as well as discussions with licensee representative, yielded several items of note. First, the various emergency medical kits onsite are inventoried only on an as needed basis. Second, none of the emergency kits are secured with breakaway locks or seals to ensure tampering is kept to a minimum. This applies to such items as the emergency decontamination and sampling kits and the SCBA packaging. Last, the RCP does not specify the contents and locations of all emergency kits and spare equipment, such as the control room kit, medical kits, decon kits, and where extra SCBAs and protective clothing can be found. Kit content descriptions should include the specific ranges of survey and dosimeter equipment.

40 The licensee has established the New Hanover County Emergency Preparedness Agency as a location for conducting emergency operations in the event the ECC should become uninhabitable.

In general, the licensee appears to have and maintain adequate facilities and equipment for dealing with an emergency; however, the following items should be considered for program improvement:

Update ECC library and Emergency Procedures to include location and numbers for UPMP facility fire alarm boxes (IFI 86-22-59).

Make provisions for performing computerized dispersion calculations in the ECC (IFI 86-22-60).

Include a method in the implementing procedures for correlating UF6 dispersion results and public hazard potential such that protective action recommendations can be made to the State (IFI 86-22-61).

Specify the location of portable radios used by the emergency teams in the RCP or implementing procedures (IFI 86-22-62).

Provide for periodic (monthly) operability tests on emergency communications equipment (IFI 86-22-63).

Provide for a formal inventory program for all on site medical kits (IFI 86-22-64).

Add tamper indicating devices to applicable emergency kits and equipment (IFI 86-22-65).

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- Include a description in the RCP of the contents and locations of all emergancy equipment and kits (IFI 86-22-66).

e. Training The team reviewed Section 7.2 of the RCP as well as selected course outlines and lesson plans. These reviews indicated that a formalized

! emergency preparedness training program was in place.

The team verified that designated members of the emergency organization had been trained in accordance with the program set forth in the RCP.

All responders, primary and interim, received initial classroom orientation, and retraining was given in the form of drill participation at least annually. According to the RCP, the Emergency Directors get additional retraining by formal review and concurrence on any RCP changes. Discussion with licensee representatives indicated that other members of the emergency organization are made aware of the RCP changes through supervisory indoctrination and participation in the required annual drills. To ensure that all individuals (primary and alternate) expected to respond, remain cognizant of their l

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41 responsibilities, and are aware of new aspects of the RCP, the licensee should formalize an annual classroom retraining program to include all emergency response personnel, as well as Emergency Directors.

The team also verified that the licensee had established a formalized program for training permanent radiation area workers on important aspects of the RCP. The topics included general radiation hazards and principles, evacuation procedures, assembly areas, and siren activation. This training is formally tracked, and retraining is required and given on an annual basis. One item for program improvement was noted. Employees and visitors are instructed in training and by posted signs to "run" out of the area in the event of a criticality siren. Discussions with licensee representatives indicated that the company's position on this matter was to " carefully run" out of the area, and the lesson plans for training did reflect this philosophy; however, signs for visitors did not. It was suggested to the licensee that posted signs should be modified to incorporate

" carefully run" or other words so as to reinforce the need for an orderly and timely evacuation and to avoid any panic that might ensue.

Training documentation further revealed that all first aid personnel expected to respond to injuries may not receive radiation protection training. These would include Emergency Medical Technicians working in non radiation areas on site. Although these individuals might be accompanied by trained "first aid responders" or radiation protection personnel, they should be trained on the radiation hazards they could be confronted with in this kind of situation.

The licensee's. program for conducting drills appears adequate.

Documentation was available showing the various scenarios as well as drill involvement by personnel . Types of drills included a wide range of scenarios - hurricanes, UF6 releases, fires, and criticality accidents. Again, these drills were formally documented and critiqued and the participation by offsite agencies was indicated. One item that should be noted, however, it that there is no formalized program to ensure that the survey, re-entry, and damage control team members all participate in drills on an annual basis. Although participation by these groups has been performed, the licensee needs to specify in the RCP at what frequency and to what extent these individuals will participate.

The team conducted walk-through evaluations with several members of the emergency organization including: emergency directors, building i managers, nuclear safety advisors, and security personnel. Primary as well as interim personnel for these positions were interviewed.

Personnel appeared cognizant of the RCP and their expected roles. They were aware of how they would be contacted, to where they should report, and how to augment the emergency organization. Individuals were also cognizant of the types of action that would be taken for personnel protection and accident mitigation, as well as where to find such information. One item noted during these discussions was that the i

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42 interim Emergency Director interviewed did not understand that he had the responsibility of immediately notifying offsite organizations in the event of an incident requiring such action. The team was informed that administrative items would be handled when the primary response personnel arrived. This should be clarified and emphasized not to be the case. Other aspects of the walk-through evaluations were found to be adequate.

The licensee's emergency preparedness training program was generally adequate; however, the following areas should be considered for improvement:

Alter posted evacuation instructions so that they indicate to visitors the need for a calm and timely evacuation (IFI 86-22-67).

Train the interim Emergency Directors such that they understand the full scope of their responsibility to offsite notifications as required (IFI 86-22-68).

Ensure that EMTs who may respond to injuries in radiation areas are given annual training on the radiological hazards with which they may be confronted (IFI 86-22-69).

Formalize an annual program for updating and retraining all emergency organization personnel on pertinent aspects of the RCP (IFI 86-22-70).

Ensure that all personnel designated as members of the survey, re-entry, and damage control teams participate in annual emergency drills'(IFI 86-22-71).

f. Administration and Maintenance of the Program The team evaluated the management attention, support, and involvement in the emergency preparedness program. There is an individual on site who has primary responsibility for maintaining the emergency program -

the Manager, Emergency Preparedness and Security. The responsibilities of this individual are well delineated in the RCP, and it appears that he has adequate background and skills to perform this function.

Although this individual occup'ies a dual rule as Manager of Security, the time dedicated to emergency response activities appears adequate.

The licensee had provided a system for management control of emergencies. The procedures delineate the various emergency response positions, who should fill them, and the actions they should take; however, there was not a complete description of these emergency positions and the corresponding responsibilities in the RCP (with the exception of the Emergency Director). In addition, the responsibilities noted for the Emergency Director should include more specific items such as emergency termination, protective action decision making, and the need for offsite notifications.

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Discussions with licensee representatives revealed that adequate manpower was available onsite at all times to handle an emergency situation. Although the availability of fnctional groups was given in the RCP, no minimum staffing levels have been provided. This should be included in the RCP to ensure that manpower evaluations have been performed and that an adequate capability is always present.

The licensee had provided for an annual review of the emergency preparedness program. This internal review was performed by key members of the management organization, and there was a formal method of concurrence to ensure that all responsible individuals provided input. The team confirmed that such reviews had been performed annually. In addition, external audits are required every two years by the license. These audits, performed by Quality Assurance and Reliability Operations, evaluated the licensee's RCP, procedures, facilities, and equipment. Although a specific audit checklist was not available for review, discussions with licensee representatives indicated that neither personal visits to offsite authorities, nor an evaluation of offsite capabilities, were incorporated into the audits.

This type of evaluation should be provided for in this audit. Document review confirmed that these audits had been performed in 1983 and 1985, and the results were forwarded to plant management and kept on file. A review indicated that the licensee had followed-up appropriately on these audit findings.

The licensee's method for distributing changes to the RCP and procedures needed improvement. Although there was a method in place for the performance of this task, the coordination between implementation, approval, and distribution of the RCP was marginal.

Changes to the RCP, if they do not decrease its effectiveness, should be distributed, implemented, and sent to NRC (in that order). Also, during the inspection offsite agencies were identified who did not have current copies of the plan. The licensee agreed to resolve this item.

The record retention of actual incidents was reviewed. The licensee had formally documented these occurrences as well as the critiques associated with them. The event packages included a summary of events, 1

a listing of participants, and comments by observers. They were maintained by the EPC and used to modify the RCP and procedures during the next annual review.

Based on the above findings, administrative aspects of the licensee's

! emergency program appear adequate; however, the following items should be considered for improvement:

Clarifying the description in the RCP of the various emergency staff assignments to include each title and corresponding responsibilities (IFI 86-22-72).

Expand the written responsibilities of the Emergency Director to

! include the full range of his responsibilities (IFI 86-22-73).

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44 Indicate the minimum staffing levels for each functional area on site (IFI 86-22-74).

Describe and implement a more formalized method of distributing _

RCP updates to ensure that all groups requiring them do receive them before the actual implementation date (IFI 86-22-75).

g. Miscellaneous From a review of the RCP and discussions with licensee representatives several-additional items were identified as weaknesses in the emergency preparedness program and warrants licensee attention.

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45 Specific evacuation routes, assembly areas, and the location of the ECC should be designated in the RCP (on site map)

(IFI 86-22-76).

Include all maps and diagrams specified to be in the RCP (i.e., -

7.5 foot topographical map) (IFI 86-22-77).

Include a vicinity map with the location of the support fire and medical facilities (IFI 86-22-78).

Include a discussion of transient populations in Section 1.2 of the RCP (IFI 86-22-79).

Include schematic diagrams of equipment, piping, and instrumentation in the RCP (IFI 86-22-80).

Include a description of how emergency equipment should operate during an emergency (IFI 86-22-81).

• alarm actuated safety systems

• automatic and manual shutdown capabilities Include a specific discussion of the design criteria for precluding criticality accidents (IFI-86-22-82).

Include a description of the expected performance of facility structure in severe weather (IFI 86-22-83).

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