Event Notification Report for May 28, 1999

24-HOUR NRC BULLETIN 91-01 REPORT INVOLVING LOSS OF CRITICALITY CONTROL

"On 5/28/99 at 0945 hrs operations personnel discovered a 5" polybottle containing uranium bearing material leaking solution from around the top of the container. The lid was found to be loose on the polybottle. An onsight NCS Engineer responded to the scene and assessed the condition to be a loss of control such that only one double contingency control remained in place. NCSA-PLANT006 requirement #2 and requirement #12 state in part: lids provide a barrier against spilling the material and the container is not moved while the lid is loose.

"THERE WAS NO RADIOACTIVE/RADIOLOGICAL CONTAMINATION EXPOSURE AS A RESULT OF THIS EVENT.

"SAFETY SIGNIFICANCE OF EVENTS:

"Safety Significance is low due to the small amount of material that leaked (10-20 ml) and the fact that the container was upright and spaced.

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

"Sufficient leakage could have accumulated in an unfavorable geometry, i.e., a building drain. With a high enrichment to create a criticality.

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

"Geometry and spacing are the controlled parameters.

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

"Amount of material is 10-20 ml of UF4 contaminated oil at 10.77% enrichment.

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

"The geometry of the container was deficient when the lid was left loose enough to allow material to slosh inside and seep through the threads.

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

"The material was cleaned up and some material decanted into another polybottle at approx. 1230 hrs. Remaining storage areas were policed for polybottles with loose lids, none were found."

Operations informed the DOE Site Representative and the NRC Resident Inspector.

24-HOUR NRC BULLETIN 91-01 REPORT INVOLVING LOSS OF CRITICALITY CONTROL

"On Friday, May 28, 1999 at 0810 hours, Operating personnel discovered that a Nuclear Criticality Safety Approval (NCSA) Requirement was not being maintained in the X-705 Decontamination Facility. NCSA-PLANT 053.A01 titled 'Uranium Analysis and Sampling' requirement #8 states in part, Samples may be grouped together but groups shall be spaced a minimum of two feet edge-to edge. Six 250 ml sample bottles containing uranium bearing material were found within 16 inches of a polybottle.

"THERE WAS NO LOSS OF HAZARDOUS/RADIOACTIVE MATERIAL OR RADIOACTIVE/RADIOLOGICAL CONTAMINATION EXPOSURE AS A RESULT OF THIS EVENT.

"SAFETY SIGNIFICANCE OF EVENTS:

"The Safety Significance is low since all the material is less than 10% enrichment, the sample batch is less than 2 liters, and some spacing was provided.

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

"Numerous spacing violations of highly concentrated uranium solutions can lead to a criticality in the absence of volume and/or geometry controls.

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

"Volume arid Interactions were the controlled parameters. Interactions was lost.

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

"Six 250 ml sample bottles were involved containing various uranium bearing solutions of uranyl nitrate and/or uranyl fluoride. Enrichment is not expected to be greater than 10%.

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

"The applicable controls are volume and spacing. Spacing between the samples and the polybottle was lost.

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

"The spacing controls were corrected at 0900 hrs."

Operations informed the DOE Site Representative and the NRC Resident Inspector.

NON-CFR REPORT INVOLVING ACTUATION OF A SAFETY SYSTEM

"ON MAY 28, 1999, AT APPROXIMATELY 1714 HOURS THE HOIST BRAKES ON THE SOUTH TAILS WITHDRAWAL CRANE ACTUATED. THE ACTUATION OCCURRED WHILE A FULL 14-TON LIQUID UF6 CYLINDER WAS BEING PLACED ON A RAIL CAR TO BEGIN THE REQUIRED 5-DAY COOL DOWN PERIOD. THE CRANE BRAKES FUNCTIONED AS DESIGNED TO PREVENT FURTHER MOVEMENT OF THE LIQUID UF6 CYLINDER. FOLLOWING THE ACTUATION. THE CYLINDER WAS SUSPENDED APPROXIMATELY TWELVE (12") INCHES ABOVE THE RAIL CAR CRADLE. THE EXACT CAUSE FOR THE ACTUATION IS CURRENTLY UNDER INVESTIGATION. HOWEVER, THE ACTUATION IS BELIEVED TO HAVE BEEN CAUSED BY A MALFUNCTION OF THE MECHANISM THAT KEEPS THE BRAKES IN AN OPEN POSITION WHEN LOADS ARE BEING RAISED AND LOWERED. PENDING FURTHER INVESTIGATION INTO THE CAUSE FOR THE BRAKE ACTUATION, THE BRAKE ACTUATION IS BEING CONSIDERED A VALID SAFETY SYSTEM ACTUATION AND REPORTABLE IN ACCORDANCE WITH THE SAR,TABLE 6.9, CRITERIA J2.

"AS A PRECAUTIONARY MEASURE THE PLANT SHIFT SUPERINTENDENT DIRECTED THAT ALL LIQUID UF6 HANDLING CRANES BE TAGGED OUT-OF-SERVICE PENDING THE NOTED INVESTIGATION. NOTE AS A PRECAUTIONARY MEASURE SUPPORT CRADLES HAVE BEEN POSITIONED TO SUPPORT THE SUSPENDED LIQUID UF6 CYLINDER. CURRENT PLANS ARE TO LET THE CYLINDER COMPLETE THE REQUIRED 5-DAY COOL DOWN PERIOD PRIOR TO INITIATING FURTHER ACTIONS TO LOWER THE CYLINDER ONTO THE RAIL CAR.

"THERE WAS NO LOSS OF HAZARDOUS/RADIOACTIVE MATERIAL OR RADIOACTIVE/RADIOLOGICAL CONTAMINATION EXPOSURE AS A RESULT OF THIS EVENT."

OPERATIONS INFORMED THE DOE SITE REPRESENTATIVE AND THE NRC RESIDENT INSPECTOR.

LOSS OF IODINE-125 SEEDS INTO SANITARY SEWER

"On May 28, 1999, two I-125 sources, with a combined activity of 0.584 mCi, were lost from the Medical Center. The seeds had been implanted into a patient's prostate earlier in the day. The patient had been instructed to save his urine so that any seeds passed in the urine could be recovered. An instruction sheet was posted on the door, directing that all urine, trash and linen be saved, and nurses had been trained for the procedure. A nurse called nuclear medicine to report that two seeds were in the urine container. When nuclear medicine personnel arrived to recover the seeds, the urine had been flushed into the sanitary sewer by another staff member on the floor.

"The toilet and urine container were surveyed with a portable low-energy gamma detector, and no residual activity was detected. The sources are presumed to have gone into the sewer, and assuming the seeds remain covered by water, no significant exposure is expected to any individual member of the public. On June 1, 1999, the loss of the sources was reported by phone to the VA National Health Physics Program.

"In order to prevent recurrence of this type of incident, the nurses on ward 7A have been retrained in the proper procedures. In the future, implant patient rooms will be posted with larger signs saying 'hold urine, trash, linen'."

* * * UPDATE AT 0950 EDT ON 6/25/99 BY KELLY MAYO TO FANGIE JONES * * *

Corrected reporting criteria from 10 CFR 20.2201(a)(1)(i) to 10 CFR 20.2201(a)(1)(ii) as the activity was more than 10 times the limit, but less than 1000 times the limit. Notified the R2DO (Al Belisle) and NMSS (Larry Camper)..