Event Notification Report for March 05, 2002

24-HOUR REPORT DUE TO TS VIOLATION INVOLVING A FUEL ELEMENT NOT INSERTED IN ITS PROPER LOCATION DURING REFUELING

"This is a 24-hour Notification regarding a violation of Technical Specification 3.4.3. Following a major refueling
and rod calibrations, the reactor was started up in accordance with Operating Procedure 101, Reactor Startup. The
reactor reached 2 MW on 6 March 2002 at 19:22 hours. The following morning 7 March 2002 at 08:16 hours, the
reactor was promptly shut down when the Day shift operating staff noted that core location 77 was open, and did
not contain a fuel element, reflector, sample holder or experimental facility as required by Technical Specification
3.4.3."

"The licensee identified safety concerns with respect to Technical Specifications 2.1.1 (safety' Limits in the Forced
Convection Mode), 2.1.1 (Safety Limits in the natural Convection Mode), and 3.1.4 (Reactivity Limits). This
occurrence may also involve unanalyzed conditions with respect to their Safety Analysis Report. The safety concerns and unanalyzed conditions include: reactor operation in forced convection at 2MW with an open grid location
providing bypass flow: a fuel element being in natural convection cooling mode with the reactor operating above
100 KW; and a fuel element outside the normal configuration while the reactor is critical."

"Description of Occurrence"

"4-5 March - Refueling during dayshift
5 March 18:15 - Commence reactor startup in forced convection mode for Rod Calibrations between 5 and 59 KW.
6 March 16:05 - Complete Rod Calibrations, shut down reactor
17: 10 - Reactor Startup
17:29 - 500 KW Checks
17:32 - 1 MW, Calorimeter commenced
18:50 - Calorimeter completed
19:22 - Raise reactor power to 2 MW"

"7 March 08:1 6 - Reactor Shutdown"

"During this time indicated primary coolant flow was between 1053 to 1073 gallons per minute. A review of all nuclear instrument channel recorders showed no unusual indications. The core excess reactivity and measured core worth were all normal."

"Core inspections were performed by many members of the operating staff as required by procedures during this
time. During refueling, all fuel handling was done with at least two persons observing. A core inspection was
performed immediately after refueling was completed. In addition, three core inspections were performed during
building checks while rod calibrations were in progress, a core inspection was made during the Reactor Startup's
500 KW checks, and core inspections were made by the Swing and Mid shifts during building checks while operating at 2 MW. No abnormalities were noted on any of these inspections. Shortly after 08:00 on March 7, the Day shift operating staff inspected the core and noted that location 77 was open. The shift supervisor promptly shut down the reactor and informed both the On-Call Supervisor and the Reactor Manager."

"A review of this occurrence has concluded that when grid location 77 was refueled, fuel element #304 ended up with its bottom nose cone outside the grid plate, while the bottom edge of the fuel element came to rest on the outside edge of the grid plate. The top of the slightly tilted fuel element was directly over location 77. Thus the element appeared, when inspected from above, to be correctly seated. Eventually, the element shifted to a vertical orientation caught between the edge of the grid plate and the nearby pneumatic tube bundle. Once the element shifted, the open location 77 became apparent and the reactor was shut down."

"Safety Implications"

"Two main issues have been identified: (1) The effect of an open grid location on forced convection operation at 2 MW; and (2) the effect on the fuel element #304 of operating it in natural convection mode. Analyses are being performed on both issues. A pool water sample was taken and analyzed. The pool water analysis was compared to past analyses of fuel element cladding failures. No fission products were noted. Fuel element #304 has been temporarily secured with a line to prevent failing off the grid plate. Procedures are being developed to remove the fuel element and will receive approval of the Safety Review Committee prior to implementation. The reactor remains in operation as required by Technical Specifications, but is shutdown (zero power). Analyses are being performed on these conditions to determine their full impact."

"Root Causes"

"The Reactor Manager and Operations staff reviewed the occurrence. The root cause investigation is ongoing."

"Immediate Corrective Actions"

"The reactor was shut down and will not be restarted for sustained operation until an operational review of this reportable occurrence is made and presented to the Safety Review Committee. An initial outside review of this occurrence has been made by the Dow Chemical Company, Midland, Michigan. A closed-mouth hook (carabiner) has been lowered on a line with a stainless steel leader and attached to the handling bail of element #304 to ensure it does not fall off the grid plate."

LOST LICENSED NUCLEAR MATERIAL >10 TIMES

"On or about March 5th, 2002, Western Research Institute (WRI) received a telephone call from [ ], of Princeton Gamma-Tech. Inc. (PGT) [ ] inquiring about the status of a PGT-100 X-Ray Chemical Analyzer (s/n 192) originally purchased by one of WRI's predecessor organizations in February, 1976. This instrument contained a sealed 50 mCi iron (Fe-55) source (NER-462) and was used to measure the sulfur concentration in materials by means of X-ray fluorescence. We have conducted a search of our records to determine the history of this device.

"WRI is not licensed to possess Fe-55, nor does the PGT analyzer appear in WRI's radiation safety records, which began in August of 1992. The analyzer does, however, appear in WRI's property records up to about 1990 when we believe it was disposed of in one of three procedures being used at that time. These procedures included disposal in the local landfill, sale or transfer as surplus property, and sale as scrap metal. Unlike other items disposed of before and after that time, the excess-property transfer form for the PGT- 100 was not signed or dated, providing no leads to the ultimate fate of the PGT- 100 and its Fe-55 source. On one property listing dated May 14, 1990, there is a hand written note: 'EX 6-8-88 to U/W' [ ]. Neither the properly office nor radiation safety office at the University of Wyoming has found a record of the PGT analyzer.

"To assist our search for the instrument [ ] faxed copies of the POT records concerning the analyzer [ ]. These records show that the Fe-55 source was replaced and wipe tested on approximately two-year intervals: Jun. 1, 1978; Oct. 29, 1980; Sep. 22, 1982; and Aug. 8, 1984. There are no records concerning the analyzer at PGT after August of 1984. Based on a half-life of 2.6 years for Fe-55, the remaining activity of the source as of April 2002 is about 0.45 mCi, still 4.5 times the level requiring labeling.

"WRI's predecessor organizations during the relevant time period were the Lararnie Energy Research Center (LERC), an office of U. S. Energy Research and Development

"Administration (ERDA, 1975-l977): and the Laramie Energy Technology Center (LETC), a field office of the U. S. Department of Energy (DOE, 1977-1983). In April of 1983, the organization was de-Federalized and absorbed by the University of Wyoming as the Western Research Institute, an independent research corporation operated as an adjunct to UW as a wholly owned subsidiary of the UW Research Corporation. While operating as a field office for ERDA and DOE, LERC and LETC were exempt from NRC licensing. As WRI, from April of 1983 to August of 1992, radiation activities at WRI were conducted under the umbrella of the University of Wyoming's NRC license. In August of 1992, WRI received its own NRC license.

"Although the undocumented transfer or disposal of the PGT analyzer occurred prior to WRI obtaining its NRC license, WRI has made an effort to find the analyzer and documentation of its disposal. We have exhausted the obvious avenues of search and cannot determine with certainly the fate of the PGT analyzer and its Fe-55 source."

R4 (Garcia) was informed by Licensee.