Event Notification Report for June 04, 2002

NRC BULLETIN 91-01 RESPONSE -- FAILURE TO MAINTAIN A DOUBLE CONTINGENCY INVOLVING TWO CONTROLS ON THE MASS PARAMETER (24-Hour Report)

The following text is a portion of a facsimile received from Paducah personnel:

"A container of improperly exempted uranium hexafluoride compressor parts was discovered in the C-333 process building which had not been characterized for storage as a group, in violation of the governing Nuclear Criticality Safety Approval NCSA GEN-010. NCSA GEN-010 requires individual items to be either spaced or grouped. Grouping is allowed if mass requirements are met. These items were not identified as GEN-010 items and had been stored as an unanalyzed group. The purpose of the GEN-010 requirement is to ensure that only safe mass items/groups are handled."

"The NRC Resident Inspector has been notified of this event."

"PGDP Assessment and Tracking Report No. ATR-02-2713; PGDP Event Report No. PAD-2002-017, Event Worksheet 38966"

"Responsible Division: Engineering"

"SAFETY SIGNIFICANCE OF EVENTS:"

"Double contingency was not maintained because the independent determination of mass had not been performed. The independent determination of mass has since been performed and [was] found to be less than the maximum safe mass."

"POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO(S) OF HOW CRITICALITY COULD OCCUR:"

"In order for a criticality to be possible, more than a critical mass would need to be accumulated in an unsafe geometry."

"CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.):"

"The controlled parameter is mass."

"ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS LIMIT AND % WORST CASE CRITICAL MASS):"

"A non-destructive analysis was conducted and determined the mass of U235 in the parts was less than 91 grams; the always-safe mass at the assay involved is [ ] grams of U235."

"NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION OF THE FAILURES OR DEFICIENCIES:"

"Double contingency is maintained by implementing two controls on the mass parameter."

"The first leg of double contingency is based on determining the mass of the group. The mass was not determined during the legacy characterization process. Therefore, the control was violated."

"The second leg of double contingency is based on independently determining the mass of the group. The mass was not determined during the legacy characterization process; therefore, the control was violated. Since there are two controls on one parameter, the mass parameter was not maintained and double contingency was not maintained."

"Since double contingency is based on two controls on one parameter, double contingency was not maintained."

"CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED:"

"Use the independent NDA results in conjunction with approved plant procedures to establish and post these items as a GEN-010 group."

Paducah personnel reported that the information provided via facsimile (and quoted above) does NOT contain sensitive information.

AGREEMENT STATE REPORT - DEFECTIVE PACKAGING OF RADIOACTIVE MATERIAL SHIPMENT

The State provided the following information regarding a previously unreported event via facsimile:

"On June 4, 2002, the surface and 1 meter radiation dose rates from a package containing 8 curies of phosphorus-32 (P-32) was found to be 1 R/hr at the surface and 4 milliR/hr at 1 meter. The package had a Yellow II label affixed which has a surface dose rate limit of 50 milliR/hr and a dose rate at 1 meter of 1 milliR/hr per Massachusetts regulation 120.775(A)(1). There was no removable contamination on the package hence the inner container appeared to be intact. However, the inner container appeared to be loose in the packaging rather than in the fixed geometry as evidenced in other similar packages in the same shipment.

"The package dose rate at the surface is greater than 0.2 R/hr but less than 0.01 R/hr at 1 meter hence the package exceeded the requirements of a Yellow III.

"In summary the defective packaging resulted in a radiation field at the surface of the package in excess of the limit for a common carrier and the Yellow II label on the package.

"The licensee has suspended all shipments from this supplier until the investigation of the package failure is complete.

"The root cause investigation of this event by the licensee has been postponed until September with the approval of the Massachusetts Radiation Control program pending decay of the radioactive material and adherence to the Perkin Elmer Life Sciences ALARA policy. A preliminary investigation concluded that persons handling the package during shipment would not have received a significant radiation dose because of the limited area of the package in excess of Yellow Il limits and the limited time of handling package by transportation personnel.

"UPDATE

"Excessive radiation field is due to seepage of radioactive material from cracked glass vial. There is a metal cap used to seal the vial. The metal cap is fastened using a hand operated crank. This tool can be mishandled resulting in over-tightening of the cap and causing the glass to crack. This vial, cap and tool are provided by Perkin Elmer and the firm is familiar with this potential failure mode. Root cause: improper training or supervision of operator of capping tool.

"Licensee informed vendor that supplies the glass vial and have discontinued using this vendor. This event is closed by the state"