Event Notification Report for January 07, 2005

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THIS IS NOT A NEW REPORT.

This event report was originally withheld from public release under the NRC's policy for protecting sensitive unclassified information. The NRC has reevaluated this policy and is now making this event report available to the public with suitable redactions.
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FAULTY PROGRAMMABLE LOGIC CONTROLLER (PLC) FOR OXIDE DISSOLUTION OPERATION

The Nuclear Fuel Services, License # [DELETED], reported that a faulty PLC evoked an event that degraded the safety conditions of the plant. Their comments are described below in a statement/answer format. The statement is cited first and the answer follows.

"Actual or potential health and safety consequences to the workers, the public, and the environment, including relevant chemical and radiation data for actual personnel exposures to radiation or radioactive materials or hazardous chemicals produced from licensed materials (e.g., level of radiation exposure, and duration of exposure):

"There were no actual health and safety consequences to workers, the public, or the environment. There were also no personnel exposures to radiation, radioactive materials, or hazardous chemicals produced from licensed materials. The potential Nuclear Criticality Safety (NCS) consequences for workers were low given the very low likelihood of adding a sufficient mass of a more reactive/incorrect material type to the system.

"The sequence of occurrences leading to the event, including degradation or failure of structures, systems, equipment, components, and activities of personnel relied on to prevent potential accidents or mitigate their consequences:

"On January 7, 2005, it was determined that the Programmable Logic controller (PLC) for the oxide dissolution operation had a negative holdup value. Upon investigation, a negative holdup value in the PLC results in the PLC using an artificially high mass limit. This could allow the system mass limit to be exceeded. The PLC is an item relied upon for safety and is credited as one of the mass controls in the safety basis.

"Discuss whether remaining structures, systems, equipment components, and activities relied on to prevent potential accidents or mitigate their consequences are available and reliable to perform their function:

"The remaining activities relied on to prevent potential accidents are available and reliable to perform their function. Operations personnel verified that the correct material type and quantity was added to the system.

"Actions taken in response to the event:

"The operation was shutdown until compensatory measures can be put in place.

"Safety Significance of Event:

"The safety significance was low for the event given the very low likelihood of adding a sufficient quantity of a more reactive/incorrect material type to the system. A more reactive/incorrect material type was not added to the system. It should also be noted that this other/incorrect material type is not present in the facility.

"Brief scenario of how a criticality could occur:

"In order for a criticality to occur, multiple occurrences of an excessive amount of a more reactive/incorrect material type would have to be added to the system.

"What are the controls or control systems and the failures or deficiencies?

"The controls were limitations on the mass and material types input into the system. The PLC is used to control the mass input into the system. The PLC for the oxide dissolution operation had a negative holdup value. Upon investigation, a negative holdup value in the PLC results in the PLC using an artificially high mass limit. This could allow the system mass limit to be exceeded. The PLC is an item relied upon for safety and is credited as one of the mass controls in the safety basis

"What are the corrective actions taken and when was each implemented?

"On January 7, 2004, the operation was shut down. Compensatory measures are in the process of being developed."

The licensee notified the NRC Resident Inspector.

* * * UPDATE ON 05/11/08 BY J KOZAL * * *

THIS IS NOT A NEW REPORT.

This event report was originally withheld from public release under the NRC's policy for protecting sensitive unclassified information. The NRC has reevaluated this policy and is now making this event report available to the public with suitable redactions.

LOSS OF A FIRE SAFE SHUTDOWN SUCCESS PATH

"On January 07, 2005, conditions were discovered where a postulated fire could cause the loss of a fire safe shut down success path. Wolf Creek is in Mode 1, at 100 % power.

"During reviews associated with post fire safe shutdown reanalysis work, Wolf Creek personnel discovered that power and control cables for Boron Injection tank (BIT) inlet valve EMHV8803A could be damaged by a fire in Fire area A-1. This valve is needed because the A train is the protected train for this fire area. This does not meet our commitments to 10 CFR50 Appendix R.III.G as reflected in our approved Fire Protection Plan.

"Following a fire in the plant that requires a plant shutdown the function of the CCP and Bit Inlet valve is to inject borated water into the reactor to maintain reactor water inventory. A fire in this fire area (A-1) has the potential to cause the above-mentioned valve to not function properly and cause a loss of the capability to maintain inventory. Based on the guidance provided in NUREG 1022, Revision 2, this situation meets the criterion of 10 CFR 50.72(b)(ii)(B) for an 8 hour ENS notification, as it relates to being in an unanalyzed condition.

"The licensee has implemented a 1-hour fire watch in this fire area.

"The licensee has notified the NRC Resident Inspector."

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The State of Nebraska reported that 19 tritium exit signs that were held under general license by Albertsons Grocery Store are missing from a store location in Omaha. The signs were manufactured by NRD, Inc., Model T-4001, with each sign containing 19.8 Curies of tritium in 1991. The State was informed in October of 2004 by Albertsons that the Omaha store had been sold to a "No Frills" supermarket chain. The State contacted "No Frills" in November 2004 and was informed that the signs could not be located. Investigation determined that the signs were removed by Albertsons in 2002 when the store was remodeled and replaced with electrical exit signs. The Albertsons store manager at the time of the remodeling was not aware of what was done with the signs. The State also confirmed that with NRD, Inc. that the signs had not been returned to the manufacturer. The State believes that the signs were probably sent to a landfill and plans to close the investigation.

BULLETIN 91-01 REPORT ON FAILURE TO FOLLOW CRITICALITY CONTROLS

Licensee performed plant walk downs in the site process buildings in January 2005 and determined that verbatim compliance with the nuclear criticality safety controls for safety arrays were not maintained. Items placed in storage after survey for contamination were subsequently found to exceed fissile exempt limits. Specifically, the Uranium-235 (U-235) mass was not determined prior to placement in storage. The failure to determine the U-235 mass prior to placement in storage constituted a violation of an administrative control in the approved safety evaluation.

All corrective actions related to this condition have been completed. Mass analysis of the storage items in question revealed that all items were well below U-235 mass limits.

The licensee states that this event has minimal safety significance.

NRC Region 3 has been notified. The licensee also plan to inform the State of Missouri.

AGREEMENT STATE REPORT OF RADIOGRAPHY CAMERA MALFUNCTION

"Radiography operations were being performed with an AEA Technologies Model 741 camera with a 33 Ci source of Cobalt-60. The radiographers could not get the source to return to the shielded position. It was determined that a mechanical failure had occurred in the connector to the drive cable which transports the source from its shielded position into the exposure position and back again. The mechanical failure is being analyzed by the equipment manufacturer. "

The Louisiana Department of Environmental Quality stated that one of the individuals involved in the event received a film badge dose of 2552 mRem.

State report ID is LA050001

AGREEMENT STATE MEDICAL EVENT

The following report was received from the Massachusetts Department of Public Health and Radiation Control via facsimile:

"Endocrinologist ordered thyroid uptake study on a patient - dose to be 17 uCi of I-131. The Central Booking Department scheduled the patient to arrive in the Nuclear Medicine Department for an I-131 'total body scan.' On 1/4/05, CNMT 1 received the appointment roster form for 1/7/05, posted it on exam scheduling bulletin board, and placed the order for a total body scan - which is generally 3.7 mCi of I-131 - without looking at the diagnosis. Total body scan ordered on roster was reviewed by Nuclear Medicine Physician and checked off for that day's activity. On the day of the exam, CNMT 2 retrieved the paper work and administered the 3.7 mCi, I-131 whole body scan. Patient sent home and came back 2 days later for thyroid scan. The imaging CNMT 3 noted that the thyroid scan did not look as expected, thus, reviewed all the paperwork and discovered that the wrong procedure (and dose) was administered. The Nuclear Medicine Physician and the RSO were then immediately notified by the CNMT 3, who in turn, notified the prescribing Endocrinologist. The Nuclear Medicine Physician then notified the patient (on 1/7/05) and the Department Administration. A summary report will be sent to the patient which will include notification that a formal report has been submitted to the Massachusetts Radiation Control Program.

"The patient ultimately received 3.6 mCi of I-131, had a thyroid uptake of 70% which resulted in a thyroid dose of 13,111 rads and a TEDE of 2.6 rads. This dose will be taken into consideration when the patient is treated next for hyperthyroidism."