Information Notice No. 97-42: Management Weaknesses Resulting in Failure to Comply with Shipping Requirements for Special Nuclear Material

                                       UNITED STATES
                               NUCLEAR REGULATORY COMMISSION
                                  WASHINGTON, D.C.  20555

                                       June 27, 1997

                               FAILURE TO COMPLY WITH SHIPPING                 
                               REQUIREMENTS FOR SPECIAL NUCLEAR                


All fuel cycle conversion, enrichment, and fabrication facilities.


The U.S. Nuclear Regulatory Commission (NRC) is issuing this information
notice to alert addressees to three recent events involving the inadvertent
shipment of Special Nuclear Material (SNM) to or from NRC-licensed fuel
facilities and the apparent root causes of these events.  It is expected that
recipients will review the information for applicability to their facilities
and consider actions, as appropriate, to avoid similar problems.  However,
this notice does not contain any NRC requirements; therefore, no specific
action nor written response is required.

Description of Circumstances

The first event involved an NRC licensee's unintentional shipment of a low
enriched uranium fuel assembly to a foreign country.  The unirradiated
assembly was part of a larger shipment that had previously been received by
the licensee for non-routine pellet downloading and reclamation.  However, one
assembly was never removed from its original shipping container and was
subsequently returned to the country of origin, in a supposedly empty
transport container.  This assembly was not confirmed as missing by the
licensee until about 6 weeks later.  NRC considered this event to be
significant in that it involved deficiencies in several program areas.  The
apparent root cause of the event was determined to be a deficiency in the
management oversight of special processes.  Contributing causes included the
failures to:  (1) follow plant procedures for the downloading process; (2)
provide adequate and detailed procedures for the downloading process; (3)
adequately evaluate the results of the container radiological survey; (4)
comply with numerous requirements for the shipment of licensed material; and
(5) implement adequate material control and accounting (MC&A) procedures and
practices to verify the presence of the fuel assembly.

The second event involved the unexpected receipt of SNM from another country
in a shipment of shipping containers that had been designated empty.  An
initial examination of the inner shipping containers by the NRC licensee
indicated two containers were not empty.  The two containers were quarantined
after being opened and a third container was later 

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identified by radiation surveys and also placed in quarantine.  The foreign
shipper identified the cause and incorporated corrective actions to prevent
this or similar events from recurring.  The shipper's corrective actions
included procedural, physical instrumentation, and systems-related

In the third event, an NRC licensee mistakenly placed two fuel rods in a
replica assembly that was shipped to a foreign country for training purposes. 
In this case, facility procedures involving the handling of rejected uranium
bearing rods were not followed, resulting in the two fuel rods being mixed
with non-uranium bearing rods and loaded into the replica assembly.  The
licensee did not discover that the two fuel rods were missing for approx-
imately 5 months.  This event raised several concerns, including but not
limited to the apparent failure of MC&A practices to confirm the presence of
SNM on inventory and in transit and the apparent failure to provide adequate
resources and management attention to control of special processes.  


The inadvertent shipments of SNM concerns NRC because of the apparent lack of
management oversight and lack of attention to non-routine work involving
special processes and the inadequately implemented MC&A programs.  Based on
the root-cause analyses of these events, the major contribution to the failure
of prevention and detection of the unauthorized shipment was a failure to
evaluate off-normal operations with the same level of review accorded normal
activities.  Although the reduced protection to the public safety was very
minimal during these events, the potential for public concern and for risk of
radiation exposure and contamination exists.  The inadvertent shipment of SNM
should have been avoided, in some cases, if discrepancies between package
radiation levels and contents (e.g., greater than background levels on "empty"
packages) were investigated before the package was offered for transport. 
Further, licensee personnel involved with the receipt of SNM packages should
be aware of the possibility of mislabeled containers and be provided with
appropriate guidance for conducting inspections and surveys within an
appropriate time period after receipt.  Licensee management should actively
encourage the analysis, evaluation, and preparation for off-normal operations,
and provide the attention and resources to assure adequately implemented
safety and safeguards programs.  The same emphasis placed on safety and
safeguards for normal operations must be equally applied to off-normal

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This information notice requires no specific action nor written response.  If
you have any questions about the information in this notice, please contact
one of the technical contacts listed below or the appropriate regional office.

                                          signed by

                                   Elizabeth Q. Ten Eyck, Director
                                   Division of Fuel Cycle Safety 
                                     and Safeguards                                       
                                   Office of Nuclear Material Safety
                                     and Safeguards

Technical contacts:  Charles A. Hughey, Region II
                       (804) 847-7343

                       D. L. Whaley, NMSS

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