ML22123A050
| ML22123A050 | |
| Person / Time | |
|---|---|
| Site: | BWX Technologies |
| Issue date: | 06/06/2022 |
| From: | Laura Dudes Region 2 Administrator |
| To: | Bittner J BWXT |
| References | |
| EA-21-035, EN54751 | |
| Download: ML22123A050 (13) | |
Text
June 6, 2022
Mr. James J. Bittner Vice President and General Manager BWXT Nuclear Operations Group, Inc.
P.O. Box 785 Lynchburg, VA 24505-0785
SUBJECT:
BWXT NUCLEAR OPERATIONS GROUP, INC. - LYNCHBURG - NRC INSPECTION REPORT NO. 07000027/2021006 AND APPARENT VIOLATIONS
Dear Mr. Bittner:
This letter refers to inspections conducted by the U.S. Nuclear Regulatory Commission (NRC),
between July 1, 2020, and March 5, 2021 at your BWXT Nuclear Operations Group, Inc.
(BWXT)-Lynchburg, VA facility. The purpose of the inspections was to review the circumstances involving a fire in the supercompactor facility that occurred on June 19, 2020.
The incident resulted in the loss of life of a BWXT employee. The enclosed report presents the results of these inspections. A final exit briefing was conducted (telephonically) with you and members of your staff on June 6, 2022.
Based on the results of the inspections, five apparent violations were identified and are being considered for escalated enforcement action in accordance with the NRC Enforcement Policy.
The current Enforcement Policy is included on the NRCs Web site at http://www.nrc.gov/about-nrc/regulatory/enforcement/enforce-pol.html. The apparent violations involved the failure to: (1) implement the established Fire Protection Program and work area spill response requirements to control flammable liquids necessary to prevent fires from occurring; (2) minimize the amount of alcohol present in drums compacted for disposal; (3) take the necessary precautions to control ignition sources and prevent the ignition of flammable vapors; (4) maintain process safety information in the Integrated Safety Analysis that was complete and accurate in all material respects; (5) assure the adequate evaluation of the change to the supercompactor prior to implementing the change.
Because the NRC has not made a final determination in this matter, a Notice of Violation is not being issued for these inspection findings at this time. In addition, please be advised that the number and characterization of apparent violations described in the enclosed inspection report may change as a result of further NRC review. Before the NRC makes its enforcement decision, a pre-decisional enforcement conference (PEC) to discuss the apparent violations will be held. We will contact you promptly to determine a mutually agreeable date and time for the PEC, which will be held in the NRCs Headquarters office in Rockville, Maryland. This conference will be open to public observation in accordance with Section 2.4, Participation in the Enforcement Process, of the NRC Enforcement Policy.
J. Bittner 2
The decision to hold a PEC does not mean that the NRC has determined that a violation has occurred or that enforcement action will be taken. This conference is being held to obtain information to assist the NRC in making an enforce ment decision. This may include information to determine whether a violation occurred, information to determine the significance of a violation, information related to the identification of a violation, and information related to any corrective actions taken or planned. The conference will include an opportunity for you to provide your perspective on these matters and any other information that you believe the NRC should take into consideration in making an enforcement decision. In presenting your corrective actions, you should be aware that the promptness and comprehensiveness of your actions will be considered in assessing any civil penalty for the apparent violations.
Following the PEC, you will be advised by separate correspondence of the results of our deliberations on this matter. No response regarding these apparent violations is required at this time.
In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice and Procedure," a copy of this letter and enclosures will be made available electronically for public inspection in the NRC Public Document Room or from the NRCs Agencywide Documents Access and Management System (ADAMS), accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html.
If you have any questions concerning this matter, pl ease contact Eric Michel of my staff at 404-997-4555.
Sincerely,
Laura A. Dudes Regional Administrator
Docket No.: 07000027 License No.: SNM-42
Enclosure:
NRC Inspection Report 07000027/2021006
cc: Distribution via Listserv
x SUNSI Review x Non-Sensitive x Publicly Available Sensitive Non-Publicly Available
OFFICE RII/DFFI RII/DFFI RII/DFFI RII/DFFI ORA/RC NAME N. Pitoniak A. Alen - E. Michel L. Suggs S. Price NAP Non-Concur AA -Non-Concur ECM Non-Concur DATE 11/22/2021 11/19/2021 11/19/2021 11/19/2021 11/19/2021 OFFICE RII/EICS OE NMSS OGC:NLO RII/ORA NAME M. Kowal M. Lombard R. Lewis L. Baer L. Dudes DATE 11/18/2021 5/25/2022 5/22/2022 5/18/2022 6/6/2022 U. S. NUCLEAR REGULATORY COMMISSION Inspection Report
Docket Number: 07000027
License Number: SNM-42
Report Number: 07000027/2021006
Enterprise Identifier: I-2021-006-0065
Licensee: BWXT Nuclear Operations Group, Inc.
Facility: BWXT Nuclear Operations Group, Inc. - Lynchburg
Location: Lynchburg, VA 24505
Inspection Dates: July 01, 2020 to March 05, 2021
Inspectors: A. Alen, Senior Resident Inspector N. Pitoniak, Senior Project Inspector
Approved By: Eric C. Michel, Chief Projects Branch 2 Division of Fuel Facility Inspection
SUMMARY
This was an event follow-up inspection of BWXT Nuclear Operations Group to review a fire that occurred on June 19, 2020 in the supercompactor building that resulted in the loss of a BWXT employees life. The inspection was conducted in accordance with the NRC inspection procedure IP 88135.02, Plant Status - Event Review. The inspection was conducted on July 1, 2020 through March 5, 2021.
List of Violations
During the inspection, five apparent violations of NRC requirements were identified. The apparent violations involved failure to: (1) implement the established Fire Protection Program and work area spill response requirements to control the accumulation of flammable liquids necessary to prevent fires from occurring; (2) minimize the amount of alcohol present in drums compacted for disposal; (3) take the necessary precautions to control ignition sources and prevent the ignition of flammable vapors; (4) maintain process safety information in the Integrated Safety Analysis (ISA) that was complete and accurate in all material respects; (5) assure the adequate evaluation of the change to the supercompactor prior to implementing the change.
Additional Tracking Items
None.
2 PLANT STATUS
BWXT Nuclear Operations Group is authorized to receive, possess, use, store, and ship special nuclear material pursuant to Title 10 of the Code of Federal Regulations (10 CFR) Part 70, Domestic Licensing of Special Nuclear Material. The primary activity on the BWXT site is the production of fuel material containing highly enriched uranium for naval reactors. In addition, BWXT has other operations, including the production of uranium fuel for research reactors in the area of the plant known as Research and Test Reactors.
Compacting operations of 55-gallon drums containing low-level radioactive solid waste at the waste compactor or supercompactor (SC) building have been suspended since a fire and an associated fatality occurred on June 19, 2020.
INSPECTION SCOPES
Inspections were conducted using the appropriate portions of the inspection procedures (IPs) in effect at the beginning of the inspection unless otherwise noted. Currently approved IPs with their attached revision histories are located on the public website at http://www.nrc.gov/reading-rm/doc-collections/insp-manual/inspection-procedure/index.html. Inspections were declared complete when the IP requirements most appropriate to the inspection activity were met consistent with Inspection Manual Chapter (IMC ) 2600, Fuel Cycle Facility Operational Safety and Safeguards Inspection Program. The inspectors reviewed selected procedures and records, observed activities, and interview ed personnel to assess licensee performance and compliance with Commission rules and regulations, license conditions, site procedures, and standards.
SAFETY OPERATIONS
IP 88135.02 - Plant Status: Event Review (IP Section 03.06)
A. Inspection Scope:
- 1. (Closed) Written Event Report (WER) 70-27/2020-001-00: Fire and Associated Fatality in the Waste Compactor Building (EN54751)
BWXT reported an employee fatality to the Occupational Safety and Health Administration (OSHA) at approximately 11:40am (EST) on June 19, 2020, due to a fire in the SC building (i.e., OSHA reportable event under 29 CFR 1904.39(b)(1)). Later that day, at approximately 1:00pm (EST), BWXT made a concurrent event notification report, event number (EN) 54751, to the NRC's Operations Center in accordance with Paragraph (c) Concurrent Report of Appendix A to 10 CFR 70. WER 70-27/2020-001-00 was opened on July 29, 2020 (see NRC Inspection Report 70-27/2020-002 - Agencywide Documents Access and Management System (ADAMS) Accession No. ML20211L698) for the NRC to review the results of the licensee and OSHA investigations and determine if there were any NRC noncompliance(s) associated with the event.
The inspectors reviewed EN 54751 to evaluate whether the licensees response was in accordance with Appendix A to 10 CFR Part 70. Also, the inspectors conducted a detailed review of the licensees investigation report, as documented in corrective action report no.
CA-2020-0838, to understand the cause(s) of the event. The inspectors conducted an independent process fire safety review of the SC equipment, operation, and maintenance as
3 it related to the compaction of 55-gallon drum s containing flammable waste. Specifically, the inspectors reviewed waste management procedures associated with the generation, packaging, and inspection of solvent rag drums; SC operation and maintenance procedures; interviewed licensee personnel responsible for the supervision, operation, maintenance, and safety of the SC process/equipment; and reviewed evaluations associated with changes/modifications to the SC process. Lastly, the inspectors reviewed licensee investigation report no. PIRT 07-01, and associated corrective actions, for a similar fire that occurred on May 8, 2007, where a drum containing flammable waste caught on fire while being compacted in the SC. Five apparent violations were identified as part of the WER review and are described below.
INSPECTION RESULTS
==
Introduction:==
The NRC inspectors identifi ed five apparent violations of license and regulatory requirements related to BWXTs failure to control fire hazards in the SC.
==
Description:==
On June 19, 2020, at approximately 10:15 AM, a fire occurred in the SC building Hot Cell (SC Cell) area (EN 54751). The fire resulted in the death of a process operator who got caught in a flash-fire resulti ng from the ignition of approximately 25-gallons of isopropyl alcohol and associated flammable vapors that were present in the SC Cell. The accumulation of alcohol was the result of the compaction of two drums of solvent rag waste (alcohol-soaked rags generated during cleaning of SNM processing equipment). The ignition source was believed to be a spark caused by energized, bare (degraded) wires in a cable that supplied instrumentation associated with the compacted drum or puck loader/unloader table. After removing the pucks from the cell, the operator entered the compactor cell and had either direct or indirect interaction with the bare wires causing a spark that ignited the flammable vapors.
The licensees investigation identified that the hazards that led to the fire resulted, both directly and indirectly, from the process of compacting 55-gallon alcohol-rag waste drums, which contained residual amounts (up to a limit of 100-grams) of licensed material. A similar fire event occurred in May 2007. The 2007 fire was initiated inside the drum during compaction due to excess alcohol mixed with metal chippings. The licensees investigation determined the cause was inadequate procedures. NRC issued an NCV for failure to establish procedures (NRC Inspection Report 70-27/2007-005, ADAMS Accession Number:
ML072540491). Corrective actions included procedure revisions and no longer compacting drums containing solvent rags.
The licensee decision to suspend the compacting of drums following the 2007 fire resulted from a corrective action to implement a third-party recommendation not to compact flammable materials. Implementation of the recommendation was tracked via corrective action program commitments (COM) 24477 and 24622. However, in July 2012, BWXT approved a change request (CR-1038675) to resume compacting of solvent rag drums at the SC.
Analysis: The failure to control fire hazards in the supercompactor resulted in apparent violations of Safety Conditions of BWXTs license and the regulations of 10 CFR Part 70.
The apparent violations are being considered for escalated enforcement based on Section 6.3(a) of the NRC Enforcement Policy. The apparent violations are as follows:
4 Enforcement:
(a) Safety Condition S-1 of Special Nuclear Material License SNM-42 requires that material be used in accordance with the statements, representations, and conditions in the application.
Section 7.1.2, Procedures, of the License Application dated March 6, 2018, states, in part, that the Fire Protection Program shall be implemented through the Industrial Health and Safety (IH&S) Manual and other systems described in Chapter 11 of the License application. Procedures will be implemented which establish fire prevention requirements designed to prevent fires from occurring. Specifically, programs will be implemented for:... control of flammable liquids and control and permitting of ignition sources.
IH&S manual procedure HS-10-12, Work Area Spill Response, Revision 3, Section 3.0, defines a large spill as generally greater than one (1) gallon that can create hazards including flammable or explosive atmospheres. Section 6.4 states that any spill with the potential to harm personnel or adversely affect the environment, equipment or other property (or in the event of a large spill unless otherwise directed by area operating procedures) shall be addressed by the Emergency Team.
Contrary to the above, on June 19, 2020, the licensee failed to implement established Fire Protection Program and work area spill response requirements to control flammable liquids necessary to prevent fires from occurring. Specifically, an estimated 25 gallons of isopropyl alcohol, a highly flammable liquid that has the potential to harm personnel or adversely affect the environment, was allowed to spill, accumulate, and overflow a trough located in the licensees supercompactor hot cell following the compaction of drums containing alcohol rags with trace amounts of special nuclear material (SNM).
The spill was neither addressed by the Emergency Team nor authorized by area Operating Procedures. As a result, the spill and accumulation of isopropyl alcohol created a hazardous explosive atmosphere that led to a flash fire and loss of life on June 19, 2020.
This is an apparent violation of license requirements, which will be tracked as AV 70-27/2021-006-01, Failure of the Fire Protection Program to control flammable liquids.
(b) Safety Condition S-1 of Special Nuclear Material License SNM-42 requires that material be used in accordance with the statements, representations, and conditions in the application.
Section 11.4, Procedures, of the License Application dated June 13, 2019, states, in part, that Activities involving licensed material shall be conducted in accordance with written and approved procedures.
Licensee procedure M11-FAWM-011, Waste Handling Requirements for Combustible and Non-Combustible Materials, Rev. 7, requires operators to use the minimum amount of alcohol necessary to dampen rags in order to minimize the amount of free liquids in the drums.
5 Contrary to the above, the licensee did not minimize the amount of alcohol necessary to dampen rags used for the decontamination process to minimize the amount of free liquids in drums compacted for disposal. Specifically, significant excess quantities (up to an estimated 25 gallons) of isopropyl alcohol, a highly flammable liquid, was present during compacting operations. The accumulation of excess quantities of this chemical created a hazardous explosive atmosphere that led to a flash fire and loss of life on June 19, 2020.
This is an apparent violation of license requirements, which will be tracked as AV 70-27/2021-006-02, Failure to minimize free liquids in drums compacted for disposal.
c) Safety Condition S-1 of Special Nuclear Material License SNM-42 requires that material be used in accordance with the statements, representations, and conditions in the application.
Section 7.1.2, Procedures, of the License Application dated March 6, 2018, states, in part, that the Fire Protection Program shall be implemented through the Industrial Health and Safety (IH&S) Manual and other systems described in Chapter 11 of the License application. Procedures will be implemented which establish fire prevention requirements designed to prevent fires from occurring. Specifically, programs will be implemented for:... control of flammable liquids and control and permitting of ignition sources.
Section 5.1 of IH&S manual procedure HS-03-10, Control of Flammable and Combustible Liquids, Revision 8, requires that the storage, handling, and use of combustible and flammable liquids in the facility shall follow the requirements set forth by NFPA 30, Flammable and Combustible Liquids Code.
The 2018 Edition of NFPA 30, Chapter 6, Fire Prevention and Fire Risk Control, requires the following:
(1) Section 6.5, Control of Ignition Sources, subsection 6.5.1, General, states, in part, that precautions shall be taken to prevent the ignition of flammable vapors by sources such as the following: open flames, lightning, hot surfaces, radiant heat, smoking, cutting and welding, spontaneous ignition, frictional heat or sparks, static electricity, electrical sparks, stray currents, and ovens, furnaces, and heating equipment.
(2) Subsection 6.5.5, Electrical Systems, states that the design, selection, and installation of electrical wiring and electrical utilization equipment shall meet the requirements of Chapter 7, Electrical Systems. Subsection 7.3.1, General Requirements, states, that the electrical utilization equipment and wiring shall not constitute a source of ignition for any ignitable vapor that might be present under normal operation or because of a spill.
Contrary to the above, prior to June 19, 2020, the licensee failed to take the necessary precautions to control ignition sources and prevent the ignition of flammable vapors.
Specifically, the licensee failed to ensure that electrical utilization equipment and wiring did not constitute a source of ignition for any ignitable vapor that might be present under normal operation or because of a spill. As a result, an energized, bare (i.e., degraded)
6 wire associated with the supercompactor instrumentation circuit served as an uncontrolled ignition source for an ignitable vapor (isopropyl alcohol) that was present in the supercompactor hot cell. The licensees failure to control ignition sources associated with the waste compaction process contributed to a fire and loss of life on June 19, 2020.
This is an apparent violation of license requirements, which will be tracked as AV 70-27/2021-006-03, Failure to control ignition sources.
(d) 10 CFR 70.9, states, in part, that information provided to the Commission by an applicant for a license or by a licensee or information required by statute or by the Commission's regulations, orders, or license conditions to be maintained by the applicant or the licensee shall be complete and accurate in all material respects.
10 CFR 70.62(b), Process safety information, states, in part, that each licensee or applicant shall maintain process safety information to enable the performance and maintenance of an integrated safety analysis. This process safety information must include information pertaining to the hazards of the materials used or produced in the process, information pertaining to the technology of the process, and information pertaining to the equipment in the process.
Section 7.4, Process Fire Safety, of the License Application dated March 6, 2018, states, in part, that specific materials and their fire/explosion hazards are described for each process area in the ISA Summary, and that a Fire Safety Analysis has been performed to assess the potential for fire consequences in areas where those materials are present.
Contrary to the above, the licensee failed to maintain process safety information in the Integrated Safety Analysis (ISA) that was complete and accurate in all material respects.
Specifically, the Fire Safety Analysis de scribed in the Safety Analysis Report 15.21, Low Level Radioactive Waste Processes, Rev. 79 (i.e., ISA Summary) for the supercompactor did not identify the fire/explosion hazards associated with the generation and accumulation of flammable liquids and resulting vapors during the compaction of solvent rag drums.
This is an apparent violation of 10 CFR 70.9 and 70.62(b), which will be tracked as AV 70-27/2021-006-04, Failure to maintain process safety information in the Integrated Safety Analysis.
(e) 10 CFR 70.72(a) requires, in part, that the licensee "shall establish a configuration management system to evaluate, implement, and track each change to the site, structures, processes, systems, equipm ent, components, computer programs, and activities of personnel. This system must... assure that the following are addressed prior to implementing any change:
7 (1) The technical basis for the change;
(2) Impact of the change on safety and health or control of licensed material;
(3) Modifications to existing operating proc edures including any necessary training or retraining before operation;...
(6) The impacts or modifications to the int egrated safety analysis, integrated safety analysis summary, or other safety program information, developed in accordance with
[10 CFR] 70.62.
10 CFR 70.62(c)(1)(iii) requires, in part, that the licensee maintain an integrated safety analysis... that identifies... Facility hazards that could affect the safety of licensed materials and thus present an increased radiological risk.
Contrary to the above, on July 19, 2012, the licensee approved a change request (CR-1038675) through its configuration managemen t system to compact waste drums containing alcohol. The licensees evaluation failed to assure that the following were adequately addressed: the technical basis for the change, the impact of the change on safety and health or control of licensed material, modifications to operating procedures, including any necessary training or retraining, and the impacts or modifications to the integrated safety analysis or integrated safety analysis summary. Specifically, the evaluation did not adequately address:
the technical basis of the change relating to equipment design, spill response, and leakage control standards required to minimize the likelihood of fires; the impact of compacting drums containing alcohol, and the associated fire/explosion hazards, on the safety and control of licensed material; modifications to existing waste processing operating procedures (e.g., EP-719 Supercompactor Operations) and necessary training or retraining to ensure drums containing excessive alcohol were not compacted; the impacts or modifications to the integrated safety analysis (including Safety Analysis Report 15.21, Low Level Radioactive Waste Processes) to incorporate the hazards of compacting drums containing isopropyl alcohol, and how the compacting of this flammable material has the potential to create a hazardous condition for the supercompactor process.
As a result, the licensee failed to maintain an integrated safety analysis that identified the presence of isopropyl alcohol as a hazard that could affect the safety of licensed materials and thus present an increased radiological risk.
This is an apparent violation of the requirements of 10 CFR 70.72(a) and 70.62(c)(1)(iii),
which will be tracked as AV 70-27/2021-006-05, Failure of configuration control.
8 EXIT MEETINGS AND DEBRIEFS
The inspectors verified no proprietary information was retained or documented in this report.
On June 6, 2022, NRC staff presented the inspection results to James Bittner and other members of the licensee staff.
9 SUPPLEMENTAL INFORMATION
DOCUMENTS REVIEWED
Engineering Evaluations:
File No. 97-00310-01, Fire Hazards Identification for PHA-12 (Waste Treatment LLR Processes), 12/10/1997 HS-2007-311, Supercompactor Facility Fire Protection Review, 10/29/2007 HS-2020-087, Reportability Determination for Fatality/Supercompactor Event, 8/14/2020 RPTWR 05-017, Risk Assessment of Severity of Radiological Consequences for Fires and Spills Involving Radioactive Materials Under License SNM-42, Rev. 2 RPTWR 2009-012, NOG Off-Site Release Dose Estimates, 5/29/2009
Engineering Changes:
CHG-8740, Revision 15 of EP-719, (5/11/2020)
CR-1026839, Revision 13 of EP-719 Supercompactor Operations, Rev. 0 (9/21/2007)
CR-1027143, Revision 39 of NMC E46-80, Rev 0 (12/9/2008)
CR-1027568, Revision 4 of M11-FAWM-011, Rev. 0 CR-1030298, Revision 5 of M11-FAWM-011, Rev. 0 CR-1038675, Compacting Rags, Rev. 0 (7/19/2012)
CR-1043285, Revision 14 of EP-719 Supercompactor Operations, Rev. 0 (01/29/2015)
SER 11-039, Alcohol Rag Press (Phase 1) - Canceled/Withdrawn, 12/1/2016
Procedures:
E46-80, Processing Containers in the Drum Count/SGS Area, Revs. 39 and 49 M11-FAWM-011, Waste Handling Requirements for Combustible and Non-Combustible Materials, Revs. 4, 5 HS-03-05, Control of Flammable and Combustible Liquids, Rev. 8 HS-10-12, Work Area Spill Response, Rev. 3 EP-719, Supercompactor Operations, Revs. 12, 13, 14, 15, and 16 QWI 5.1.12, Change Management, Rev. 23 QWI 5.1.7, Safety Evaluation Requests, Rev. 27
Corrective Action Documents:
BWX_2017074, Fire during waste drum compaction on 5/08/2007. Report date 8/3/2020 CA 2020-0838, Fire in SC results in fatality on 6/19/2020. Report date 9/21/2020 COM-24477 COM-24478 COM-24623 COM-24624 COM-24625 COM-24622 COM-24626 COM-28444
Miscellaneous:
BWXT Correspondence No.07-105, (Third-Party) Inspection Report L060107_111, 6/25/2007 BWXT Correspondence No.07-107, BWXT Response to (Third-Party) Inspection Report L060107_111, 8/23/2007 BWXT Correspondence No.07-166, BWXT Response to (Third-Party) Inspection Report L080807.111, 11/8/2007 Daily Fixed Air Data Report for Drum Turntable and Drum Conveyor, count date 6/19/2020 N-530, Investigative Report for Supercompactor Fire/Fatality (CA2020-0838), 8/31/2020 PIRT 07-01, Investigation Report for Supercompactor Fire on May 8, 2007, 6/7/2007 Radiological Water Analysis for Emergency #1/#2 and Emergency #1/#2 Rerun, dated 6/19/2020 Radiological Water Analysis for North and South Compactor Water, dated 6/19/2020 SAR 15.21, Low Level Radioactive Waste Processes Waste Operations Rev. 78
10