e -0 UNITED STATES NUCLEAR REGULATORY COMMISSION

WASHINGTON, D.C. 20555-0001

OFFICE OF THE March 27, 2003 SECRETARY

COMMISSION VOTING RECORD

DECISION ITEM: SECY-03-0036

TITLE: REPORT TO CONGRESS ON ABNORMAL OCCURRENCES FOR FISCAL YEAR 2002

The Commission (with all Commissioners agreeing) approved the subject paper as recorded in the Staff Requirements Memorandum (SRM) of March 27, 2003.

This Record contains a summary of voting on this matter together with the individual vote sheets, views and comments of the Commission.

Annette L. Vietti-Cook Secretary of the Commission

Attachments: 1. Voting Summary 2. Commissioner Vote Sheets

cc: Chairman Meserve Commissioner Dicus Commissioner Diaz Commissioner McGaffigan Commissioner Merrifield OGC EDO PDR

VOTING SUMMARY - SECY-03-0036

RECORDED VOTES

NOT APRVD DISAPRVD ABSTAIN PARTICIP COMME

CHRM. MESERVE

COMR. DICUS

COMR. DIAZ

COMR. McGAFFIGAN

COMR. MERRIFIELD

x

x x x x

ENTS DATE

X 3/24/03

X 3/21/03

X 3/19/03

X 3/20/03

X 3/25/03

COMMENT RESOLUTION

In their vote sheets, all Commissioners approved the staff's recommendation and provided some additional comments. Subsequently, the comments of the Commission were incorporated into the guidance to staff as reflected in the SRM issued on March 27, 2003.

NOTATION VOTE

RESPONSE SHEET

TO:

FROM:

SUBJECT:

Annette Vietti-Cook, Secretary

CHAIRMAN MESERVE

SECY-03-0036 - REPORT TO CONGRESS ON ABNORMAL OCCURRENCES FOR FISCAL YEAR 2002

Approved x/with comments

Not Participating

COMMENTS:

See attachment.

Disapproved Abstain

SIGNATURE

DATE

Entered on "STARS" Yes No_

COMMENTS OF CHAIRMAN MESERVE ON SECY-03-0036

I approve the proposed Abnormal Occurrences report to Congress, subject to the edits recommended by Cmr. Diaz. However, I do not concur with the recommendation that events 02-2 and 02-3 should be deleted from the list of Abnormal Occurrences (AOs).

As stated at the beginning of SECY-03-0036, the statute requiring that the NRC report AOs to Congress defines an AO simply as "an unscheduled incident or event which the Commission determines is significant from the standpoint of public health or safety." 42 U.S.C. § 5848. If this were the only requirement on which to base an evaluation, I would agree that neither event would likely be considered as an AO. However, as noted in the preface to the AO Report (p. xi), the Commission published a policy statement containing the much more specific criteria for determination of an AO that are included in Appendix A of the report. 62 Fed. Reg. 18,820 (1997). On the basis of the specific criteria cited by the staff - criterion l.C.3 for the loss of the Millstone spent fuel rods and criterion I.C.4 for the accountability failure at NFS -- the staff's decision to include these events as AOs appears to me to be appropriate.

I believe that the Commission's published policy should govern the selection of events to be reported as AOs until and unless that policy is amended. Consequently, I recommend that events 02-2 and 02-3 be reported as AOs, and that the Commission consider separately the matter of revising the policy statement dealing with AO selection criteria.

NOTATION VOTE

RESPONSE SHEET

TO:

FROM:

SUBJECT:

Annette Vietti-Cook, Secretary

COMMISSIONER DICUS

SECY-03-0036 - REPORT TO CONGRESS ON ABNORMAL OCCURRENCES FOR FISCAL YEAR 2002

Approved X Disapproved _ Abstain

Not Participating

COMMENTS: The title of page ix in the Contents should include the word "Acronyms."

The full title should be "Acronyms and Abbreviations."

DATE I

Entered on "STARS" Yes X No

NOTATION VOTE

RESPONSE SHEET

Annette Vietti-Cook, Secretary

COMMISSIONER DIAZ

SUBJECT: SECY-03-0036 - REPORT TO CONGRESS ON ABNORMAL OCCURRENCES FOR FISCAL YEAR 2002

w/conmments & edits

Approved Lxx-7q Disapproved

Not Participating

Abstain

COMMENTS:

See attached.

I

DATE

Entered on "STARS" Yes No

TO:

FROM:

jam SIGNATUAtý

Commissioner Diaz's Comments on SECY-03-0036

Approved, subject to moving item 02-2, "Unaccounted for Fuel Pins at Millstone Unit One in Waterford, Connecticut" and item 02-3, "Accountability Failure at Nuclear Fuel Services in Erwin, Tennessee" from the AO section to Appendix C "Other Events of Interest." While I agree that these events meet the criteria for "consideration for reporting as AOs," as defined in Appendix A of the paper, they did not have any adverse affect on public health or safety for the following reasons. The staff concluded that "the current risk to human health from the unaccounted for fuel rods appears to be insignificant." The staff also indicated that the material at Nuclear Fuel Services remained at the site, inside secure storage at all times. Corresponding changes should also be made to the correspondence.

Attached are edits to the report.

CONTENTS

A BSTRACT ................................................................ iii

ABBREVIATIONS . .......................................................... ix

PREFACE ................................................................. xi INTRODUCTION ........................ .................... ....... xi THE REGULATORY SYSTEM .................................. xi REPORTABLE OCCURRENCES ........................... .......... xli AGREEMENT'STATES ............................ .......... xii FOREIGN INFORMATION ......... Xi UPDATES OF PREVIOUSLY REPORTED ABNO AL OCCURBE1

ABNORMAL OCCURRENCES IN FISCAL YEAR 2002 N&~(ýdANC d~cee~cj~ ieso(

NUCLEAR P(WERPLANTS 1....... ............... 02-1 Reactor Vessel Head Degradation e Nuclear Power Station

Sin Oak Harbor, Ohio ..... 4•............. 1 02-2 Unaccounted for Fuel Pins at Mill tone Unit

,W aterford, Connecticut.k", .......,.-,... 5

FUEL CYCLE FACILITIES:(Oth Th. ucle w lntq), 02-3 Accountability Failure Nucle n

Erwin, Tennessee K ......................... 8

OTHER NRC LICENSEES 02-4 Gamma Ste

St. Lukes N5

Ra

sVialRa•gr .tic RAjsur

sure i F, Lim

aphe&,Medical Institutions, etc.) ge `amma Knife) Misadministration at

a, kee,-Wisconsin ............... 10 ikegulatory. Limits at Pacific iolulu, Hawaii .................... 11

JTELoss. k41e Integrity and Elevated Radiation Levels Measured

FLti~ed xpress Facility in Kenner, Louisiana ............ 13 ustrialdiography Occupational Overexposure at Longview

ction in Channahon, Illinois .... ... .............. 15 -3 strial Radiography Occupational Overexposure at McShane

Idustries in Baltimore, Maryland ...................... 16 .-4 Intra Vascular Brachytherapy Misadministration at Rhode Island

Hospital, Providence, Rhode Island ..................... 17 -" Strontium-90 Eye Applicator Brachytherapy at South Broward

Hospital District in Hollywood, Florida .................... 18 -6 Industrial Radiography Occupational Overexposure at Technical

Welding Laboratory, Inc. in Houston, Texas ............... 19 -7 Diagnostic Misadministration at Cedars-Sinai Medical Center in

Los Angeles, California ............................... 21

viiNUREG-0090, Vol. 25

AGA

AS 0

AS 02

I

AS 02

AS 02

ABNORMAL OCCURRENCES IN FISCAL YEAR 2002

NUCLEAR-POWER PLANTS

Using the criteria and guidelines in Appendix A to this report, the following event that occurred at a U.S. nuclear power plant during this reporting period was significant enough to be reported as an Abnormal Occurrence (AG): , 02-1 Reactor Vessel Head Degra tion at Davis-Besse Nuclear Power Station in Oak Harbor,

Ohio .

Appendix A'(see Criter'ion Il.A:.2, "For Commercial NuclearPower'Plant Licensees") to this-report states, in part, that~an eventwill ee'considered for-reportingas an AO if it involves a serious degradation of the primary coolant pressure boundary.

Date and Place - March 6, 2002; "Davis-Besse Nuclear Power Station, a pressurized-water reactor-plant designed by Babcock and Wilcox Company, operated ,by First Energy Nuclear Operating Company and located near Oak Harbor, -Ohio. -

Nature and Probable Consequeng'c6es =_'On February 16,- 2002,ithe-Davis-Besse facility began its 13th refueling outage, Which~includedinspections oftheLcontrol rod drive mechanism (CRDM) nozzles in accordance with NRC'Bulletin 2001-01; "Circumferential Cracking -of Reactor PressureVessel Head Penetration:Nozzles;" issued-on August 3, 2001. These nozzles penetrate through the reactor pressure vessel (RPV) head and are attached by welds. Nozzle cracking was first discovered in the'industry~in the'late 1980s. T'he concern with cracking isthe potential loss of control rod drive function '(rod ejection),and the -'esultant loss-of coolant accident (LOCA) should the cracks reach a critical size and orientation.-, Also of concern is thepotential 'for the reactor coolant to leak through small c'racks in-CRDM r ozzles and cause-boric -acid corrosion of the RPV head. The RPV head is an integral part of.the reactor coolant pressure boundary (Figure 1) and loss of its integrity can likewise result in a LOCA.

On February 27, 2002, the licensee notified the NRC that non-destructive examination of CRDM Nozzles 1, 2 and 3 identified that those nozzles contained small-through-wall cracks. -The licensee-decided to repair these-three nozzles plus two other nozzles With identified cracks that did not appear to'be through-wall. The repair process included machining away the lower portion of the CRDM nozzle to a point above the cracksin the nozzle.material. :During this activity, CRDM nozzle 3 loosened in the head and on March 6, 2002; .the licensee began an investigation to identify the cause. At the same time, activities were -underway to remove.boric acid deposits from the top of the RPV head caused by leakage of reactor coolant from the cracks and past leaking CRDM flanges. After removing the boric acid.deposits, the licensee identified a large corrosion cavity in the head material adjacent to CRDM Nozzle 3 (Figure 2). The cavity was approximately 6 inches in length and four to 5 inches in width. Within this-area the 6.63 inch thick low alloy steel head was corroded away leaving only the stainless steel cladding layer on the inside. The remaining cladding layer ranged in thickness from 0.20 to 0.31 inches. -Subsequent metallurgical examination of this section of cladding identified a shallow crack approximately 3/8 inch in'length. This cladding layer is designed as a corrosion resistant layer and is not designed to retain reactor operating pressure. In addition to .the cavity adjacent

"NUREG-0090, Vol. 25 1

to Nozzle 3, a comparatively small cavity was identified adjacent to Nozzle 2. This cavity was approximately 1.75 inches wide, 4 inches long, and 0.25 inches deep.

Region Ill sent an Augmented Inspection Team to the site to determine the facts and circumstances of the head degradation, beginning on March 12, 2002, and held a public exit meeting on April 5, 2002. A-follow-up inspection identified several apparent violations of Agency regulations. The apparentviolations will be processed in accordance with Agency procedure.

On April 8, 2002, prior to discovery of the crack in the cladding, the licensee submitt.dea safety significance assessment for the degraded RPV head to the NRC. This assessmpnedetermined that the as-found stainless steel cladding layer would have remained intaeU lur nticipated operational occurrences and postulated accidents. Further, t iqassessm that had-the RPV head failed due/to the corrosion: a) adequate ooling been established and maintained for-the long term, b) the reacto ould hav ac d nd maintained in a safe shutdown condition, and, c) the integ of con ta•nment WO 0 ave been compromised. The NRC staff is performing an ind e den essment an'' [g- the adequacy f the licensee's assessment. ah, ,i c. ." .:

Cause 6r Causes - On April 18, 2002, the licensee subm'e o tCause Analysis Report to the NRC. In this report, the licensee concluded that thel:oest pro fb chnical cause of the RPV head degradation was boric acid corrosion resulting fro le gh a crack in the CRDM penetration nozzle attributable to primary-watd6r1?s coreroso o a n-g. - Further,.this corrosion had occurredover a period of several e t more d i ye information, the licensee's technical root cause analysis repres rs a p jrorrthe degradation..

The licensee has completed a number of ivities "sgne ify management and human performance issues which contributed is eve Sever ment and human performance issues were subseque --•dentifie ]y both tF licensee and NRC. NRC continues to monitor these activities and Ind n entl s he, ctiveness of the licensee's efforts in this area. . ., . ,

Actions Ta kevent re e

Licensee - e e electe a e the damaged head with one procured from the t iaa ner plant located in Michigan. The licensee has also

completed a nue es des-1[ to identify the management and human performance defcienciew i co U he degradation of the reactor vessel head and implemented a series of ectlons n i to identify and correct any other potentially problematic plant issLios. , . ar to

NR..G, 'Region III issued ' nfirmatory Action Letter (CAL) 3-02-001 on March 13, 2002, and Re)hs CAL 3-02-0012h May 15, 2002, which detailed specific licensee actions to be taken be e C would co•skýer restart of Davis-Besse. The NRC issued two Information Notices (IN.Iimond toBuljetwi1o promptly inform the industry of the event: IN 2002-11, "Recent ExpqfehathD gradation of Reactor Pressure Vessel Head"; IN 2002-13, "Possible lndic, rfe'figoing Reactor Pressure Vessel Head Degradation"; Bulletin 2002-01, "Reactor Pressure Vessel Head Degradation and Reactor Coolant Pressure Boundary Integrity"; and Bulletin 2002-02, "Reactor Pressure Vessel Head and Vessel Head Penetration Nozzle Inspection Programs."

NUREG-0090, Vol. 25 2

The NRC placed Davis-Besse Under the Inspection Manual Chapter 0350 "Oversight of Operating Reactor Facilities In a Shutdown Condition With Performance Problems" on April 29, 2002. Further inspections and assessment of Davis-Besse performance will be performed before plant restart is considered. The NRC also chartered a Lessons Learned Task Force (LLTF). The objective of this task force was to independently evaluate the NRC's regulatory processes related to assuring RPV head integrity in order to identify and recommend areas for improvement that may-be applicable'to either the NRC or the nuclear industry. The LLTF completed its evaluation and its conclusions were reviewed by a Senior Management Review Team to determine appropriate Agency.actions. The recommendations of t-,Senior Management Review Team were issued November.26, 2002. ACommis.i"n nmeting was held on January 14, 2003 to-brief the-Commission-on the Senior Managemer t FTeam recommendations -du'd CoIP6 ,r e.

This event is considered open for th "purpose of this repo,

Typical Pressurized WaterReactor

�,,-1

- .-.

"Reacwor Vwzmel Hoed

Figure 1. Typical Pressurized Water Reactor (PWR)

3NUREG-0090, Vol. 25

both input to and output from a process, the process monitoring system did not detect the failure to record in the computer that the material had been placed in the containers.

The consequence-of-the.-errors -in the material -controLprogram -was thatithere was no record that the materialhadtbeen'removed from the, process'area',and placedin the storage:area. The licensee apparently failed to meet several regulatory requirements for accounting for SSNM.

Cause or Causes - One cause was the failure~of'licensee:personnelctoifollowprocedures. Another cause was failure by the licensee to adequately investigate indications ,of.tpe'problem at the time it occurred. The licensee initiated and completed an investigatio o ide t~i 'root and contributing causes to ensure appropriate corrective tonpreventrdecurren ribed in the :next section.

Actions Taken1 to'Prevent Recurrence / -: - •-

Licensee -. Corrective a operating shifts, (2) more responsible individuals, a TIDs. As a-resultof-the'l additional corrective actic These include enhancem icompliance, and revision in the-luture-and to proml

NRC - In April 2002, the associated with the Mate and location-of containern As a result of correspond been an actual event, ani

During -Augu 9-27;-20( the correct s tak reouiremententif2002, to furthdi issued aiConfirr commitments tc to certain eleid MC&A.pe rmE Region~•Office and isganning

licl WdE

:e. Th MC&

by the

Ir

•nce enhE. on Nover

inspectior •e NRC is

pFlogra. -NRQI

ctions have included: (1) providi 1C& uees g---- I -frequentreconciliation~of MC& acies, (3) retrain

Lnd.(4) upgrading the licensee's"i procedures for missing icensee's root cause investigatio. `n'November2002, ,ns to'prevent reoccurrence we, Ien re being implemented. ients'tolhe computerizedMC&, tsystems, rocedural -of~their.system-of. check bances"to-p tch discrepancies ptly identifkyany-if'the

NRC'became awef thete c nce of a problem

rial Controlanda"ccuntin regarding identification s. The•NRC .ested: •-,license- : review-the potential occurrence. ence'with ins I e ,e NRCd•ermined in July 2002 that there had d it was~ atially si iicante h to warrant special inspection.

02 condu teiction-of the circumstances involved and ,,i disco everal apparent violations of regulatory

fied. held a management.meeting with NFS onOctober.3, he isnu-t ot causes,.and piann'ed corrective 'actions. The NRC 41 n.-Lett •NFS~on October 15,2002,-to document specific

t ons di ed by NFS in the-meeting. .NFS responded in writing n Octd er 29, 2002 and provided additionalinformationiand a

e •rogram at the management meeting with 'the NRC at.ihe 1711 r002. The NRC is continuing its review of licensee actions ns irther review the licensee's MC&A systems and procedural

o evaluating its own procedures forperforming oversight of to determine if changes might be needed so that such issues are

re promptly. Enforcement actions are-under review. -

for the purpose of this report.

9NUREG-0090, Vol. 25

'3--.

Actions Taken' to-Prevent Recurrence

inclusion in the Department of ofy spid y and HealtiiSurveillancex voluntary life-time morbidity study. • Z 61 -'-.z e-- L.LW -L

The'licensee notified the patient's referring physician, who was also the attending neurosurgeon, immediately after the event. The radiation oncologist informed the patient of the event the following day and subsequently provided a copy of the report submitted to the-NRC.

Cause or Causes - This misadministration was caused by human error, in that -licensee staff failed to verify that the treatment plan used was for the patient being treated. Licens6p staff who, participated in the itreatment did not follow.procedures requiring -verification ofpatfi nt ,specific treatment parameters prior-to delivering the radiation dose.' '-:

Actions Taken to Prevent Recurrence

Licensee-Th6 ice seeimmediatel i b1emente meas res t 'en rtelhatpatient seci parameters are confirmed and verified prior to initiation ý o.eatmerf'Te measu res ad labeling each page of the treatment plan with the patient'q• or to initiation o• ••Mnt and maintaining the treatment plan in the !Radiation Oncol priment~binder-for the patient.

NRC -The licensee was citedd.for violations'that.include ailu hat the treatment parameters implemented were .foir.the patient'being treat-.

This event is closed for the purpose of-this re,'

02-5 Extremity Exposure'in Excess egulAto its a acific:Radiopharmacy, Limited, in HonolUlu, Hawaii .

Appendix A (see Criterion l.A .'" an Exp l iation from Licensed Material") to this report states art, that a tended ra osure to an adult,(any individual 18 years of age or o sulting ir yni shalloo equivalent to'the skin or extremities of 2,500 mSv( .mor r onsidered for reporting as an AO.

Date and Place a 26 200 adiopharmacy, Limited, Honolulu,'Hawaii.

Nature and P" n ces 'During a routine, unannounced inspection conducted by the NRC oMarch 6, 20• nector observed a radiopharmacistdrawing 3700 megabe querels (MBq) [1,0 j•Lrie (mCi)] bulk doses of technetium-99m (Tc-99m) utilizing a vial shield without a shield ' top. The inspector observed that the radiopharmacist used his'left inde mger to hold the vi •,ontaining the Tc-99m in the shield when he inverted the vial to draw a dos, After questionirlhe individual, the inspector determined that this was Xfj .-ne

prd•~p •Following t ji> spection, a licensee consultant calculated the exposure to the in,'I d• . .inger to be 7000 mSv (700 rem) for calendar year 2001. 'The exposure

wa s• RC Operations Center on March 26, 2002. In addition, the licensee's con., lated the exposure to the individual's left index finger to be 1400 mSv (140 rem) from J nuary 1, 2002 through March 13, 2002. The exposure was reported to the NRC Ope tions center as a thirty day report on March 28, 2002. The radiopharmacist's extremity

U• .. -&.,,f z••1V, NUREG-0090, Vol. 25

"/t_ z

L-OIL-L..4 ' '.,\

I

exposure was chronic and not acute, occurring over the entire calendar year. The inspector viewed the individual's left index finger and did not identify any visible skin reddening.

Cause or Causes - Licensee management and the Radiation Safety Officer failed to effectively train Pacific Radiopharmacy employees on NRC requirements-and failed to provide effective

>,( oversight of its radiation safety program.

Actions Taken to Prevent Recurrence 21

Licensee- The licensee has obtained additional vial shields with shielde ,opsr aed them at the sbcond drawing station, and has required the radiopharmacist to use im e licensee also reviewed the adequacy of the radiation safety officer's o *tzight o • dtion safety program, determined it~to-be inadequate, and has replaced, d iation,- b cer with,-' another individual. The new radiation safety officer conducu nannou•a,9 e, •.•s of the radiopharmacy to ensure compliance with their procedu "equirin ue 'Ids shielded-tops during dose drawing procedures.

On March 29,-2002;'the NRC issued C6nfirmatory Action L) -4-02-,003 to the, licensee associated with the extremity exposure'in excess of regul n April 8, 2002, the licensee responded to the CALr.with -corrective actions wkincd , emoving the radiopharmacist from working with radioactive materials throughor rmainder of calendar year 2002; (2) contracting with a local consultant tp safety t nduct random unannounced audits, and provide Radiation':Saf •ce .0) servi, and (3) replacing its current RSO with the new consultant and re t e end arterly board meetings to provide safety reports to the board.,

NRC - In addition to issuance of.CA 2-003, C stf so met with licensee representatives in a Predecisionala~ oc6ment• nference, 'nOctober 10, 2002, to discuss the inspection findings. Enforcement ohn iscui•ty pend•

This event for the ofthis r. ..

NUREG-0090, Vol. 25 12

and 0.39 mSv (39 mrem) for the November-December 2001 period. The consultant concluded that there were no excessive radiation levels from the SAFKEG on either flight. The consultant's calculations estimated the highest dose to any Federal Express employee at 20 mSv (2 rem). The French and Swedish regulatory agencies evaluated the portions of the event that occurred within their jurisdications.

Cause or-Causes - On February 7, 2002, after construction of the hot cell, appropriate SPEC personnel opened the SAFKEG utilizing robotics. The tamper seal was intact; after it was broken, it was sealed in plastic and put aside. The interior shielded pot was removedand placed into a small lead shield. The shielding pot lid is normally.secured with'six allen headiscrews; however, one of the six screws was found loose. The plug assembly ac id cavity: containing the thre evials of Ir-192 disks was removed, revealit that t ree vials were open. The screw tops for the vials and a large number of Ir-Modisks re i '1e along the lip of the inner cavity" It is presumed the screw tops became 'rewed du rtation,resulting in theelevated external radiation levels.

Actions Taken to Prevent Recurren-ce

Licensee - The licensees invol•ed in this occurrence are package manufacturer, Croft" and the U. S. recipient, SP manufacturerare pursuing cd .rrective actions, but these 1i of this report.:-

Theinner-shielded pot of thep'ackage remai e thisreport.-' SPEC had no plans to'atempte her dec

"DOT -:-Prior`to the openihg of th6 cask T I s a rei -forhis 'tpe of p0ckige rei:uirihg that • ials us .for this in such a way as to require that th• $must b'el estroye opening of the keg revealed that t ocapsule d u•sCra thistypeof o rence in th " r"DOT, l7ssed

result of -thisl ~d.

State Agen ate of L' ad the lead roe has'conclued its t io.

shipper, Studsvik AB, the •er and package ,

ized as of the dateenot

' te SPEC facility at the time of .0.e pot."

id, o the'certificaie 'of cornpliance ,- of transportation, must be sealed

ob removeithecontefits. Since the ved, the DOT notice should prevent "possible enforcement action as a

n the investigatiohof this event and

e ofis report.

NUREG-0090, Vol. 25 14

AS 02-2 Industrial Radiography Occupational Overexposure at Longview Inspection in Channahon, Illinois

Appendix A (see Criterion I.A.1, "Human Exposure to Radiation from Licensed Material") to this report states, in part, that any unintended radiation exposure to an adult (anyindividual 18 years of age or older) resulting in a shallow-dose equivalent to the skin or extremities of 2500 mSv (250 rem) or an annual total effective dose.equivalent of 250 mSv (25 rem) or more will be considered for reporting as an AO.

Date and Place - The Illinois Department of Nuclear Safety (the Depart January 15, 2002, by the licensee's RSO, that in June 2000, a radiograp overexposureand subsequent injury at atemporary job.site near Chan

,Nature and Probable Consequences - On January 15,2.'th, elicensi overexposure to -a radiographer and a subsequent injury1 -could hare overexposure. The overexposure occurred in June 2000.d .invoIl va tr-192 source at a temporary job sitehear Channahon, iIIps radic the source-was secured following the~radiographic expos A p h and knelt down.without looking at'his -survey,.meter. Ther ro"g. . inoperable because 'ofalowbattery.,;Afterchangirg the 6 ' o unhooking the guide, tube6,;ehb hoticed thie source drive cal s fi, survey meter showed-an off-scale reading...He im edIr cranke shielded position. -His s'elf-reading;pocket6do' scale,. inform the licensee of.the incident., cAppaoxile.u Ar th noticed skin redness ina two centimetersid:are'ao ir-: wound became ulcerated and would not •. A-ph• 'the" -concluded that it could have resUlted f adiatio n Jan 02,th became aware of-the condition and b d jtitt eDepa ent. Prior t extensive-investigation, the Depart rt-eco e•ndedth he licensee, assistance from Oak. Ridge-Radia an E_em ergd Ass't6ce -Center/Trai The REACITS ncluded th t ury cou r tedfromthe-ove 2000. The iment p , terviews nsive time-motion,

tht heindyae described by~the -radiographier. underwent s r - .. n F a • -002. The estimated,dose to thE mSv;(1,500.rer o 5e remty

Cause or Ca - asitified as a-failure to conduct alo camera aft eI,,h source d, the failure to conduct radiation su. utilize a - erable alarmin eter due to a low batterv.-

,notified on enced an ois. - -

potentia I~th= d•

.0 T~qr8-___Z igrapher, ,, ••eV that I the guide tui&e area alarming rate meter was ,for~the next-shot and

uide--tube and his s•1e back into the

iographer did not idlnt, the radiographer

the next year, the ,individual and e licensee's RSO o ocommencing an seek-immediate ning Site-(REAC/'S). rexposure in June 3tudies and concluded rhe radio•grapher. e individual was 15,000

ckout survey of the rveys and the failure to

Actio aken to

-The lic(L 7r

"• ', , " ',- . . ..7

nt,9ecurrence - - .. ,

ie terminated the radiographer's employment and incorporated the event r training at all thirty-one Longview Inspection offices. ,

a. � �

�k�4�L�V � A� � � � MI i�:.-0090, Vol. 25

Z L.

-oy1

,APPENDIX,C

'OTHER EVENTS OF:INTEREST

This Appendix discusses "Other Events of Interest," that-do not meet the abnormal occurrence (AO) criteria but have been perceived by Congress or the public to be of high health and safety significance, have received significant mediacoverage, or,-have caused the ,NRC to 6lrease its attention to or-oversight of a program area, or a groupof-similar events'th aave/tsulted in liaensed materials entering the public domain -in an uncontrolled.manner

NUCLEARPOWER.PLANTS'.

1 . Generic Communications Related to Reactor Ves C".Qrackin ' , .'

The following events did not -mE

.r- uuL•j•, ,h: p..t. .ti. . of pu

The NRC previously issued Bull Vessel Head Penetration Nozzl{

control rod drive mechanisms a intensive and effective :inspectic circumferential cracking and lea

,identified and remediated at se'

Close-out-letters:have.been issi

Following the~ overy~ofr Section 02- ocumej Degradation " a.-or .CooP• status of license po as= other reactor coola1p • • responses toth" I . conditions t ould lea NRC 'sta "ckontinuinglo2

*assure •integrity of theo RPVb•h.

lead De6�dation1�N��le, j-'

�ed�6et the AO reporting criteria "e V' CLo:l

Jblic'health or safety. ' "

letin2001-01, "CircC ra racking ector Pressure es ;"An"August.2 ! s is oo rac identified intwo of the5 t the Oconee clear S a t- a result of more

sr1sutting, i M ej0rs Bulletin, additional kage fro sseLh peneti"r o HP) nozzles ,has been.-

veral p Accn 4,, ̂-~ k~ ^th+k -r~ ýecotiblz-+`- te th-e

ued I' of~the s "suri"e. ater reactor (P.WR) licensees.

sel ha ion.at ,Davis-Besse, as ,described in issue etin 2002-01, "Reactor.,Pressure Vessel Head 1 ae -Boundary Integrity,"-n March 2002,.to assess-the

s a rity of the reactorpressure ,vesseh;(RPV) head and boun a CPB) components. Based on.a ieview of licensee

-C:st i ncluded that no other plant-had degradation, or the ation, similar to-that identified -by the Davis-;Besse plant. The 6rmation from PWR-licensees regarding their.actionsto,

Ictor coolant pressure boundary.components ,exclusive of the

Bull 01-01 and thp V head portion of Bulletin 2002-01 provided information on the inte .VHP lnozzid and RPV heads at the time of issuance-of theBulletins and at the next ref I U•ensure.the adequacy of future inspection plans for the RPV.head and VHP no zzesued Bulletin 2002-02, "Reactor Pressure Vessel-Head and Vessel Head Penetr i ozzle Inspection Programs,",in August 2002, to advise PWR licensees ;that visual examination of the RPV head and VHP nozzles may need-to be supplemented with additional

29NUREG-0090, Vol. 25

NOTATION VOTE

RESPONSE SHEET

TO:

FROM:

SUBJECT:

Annette Vietti-Cook, Secretary

COMMISSIONER MCGAFFIGAN

SECY-03-0036 - REPORT TO CONGRESS ON ABNORMAL OCCURRENCES FOR FISCAL YEAR 2002

w/comments

Approved *" Disapproved Abstain

Not Participating

COMMENTS:

See attached comments.

SIGNATURE W0

DATE

Entered on "STARS" Yes -___ No

Commissioner McGaffigan's Comments on COMSECY-03-0036

I approve the proposed Abnormal Occurrence report contained in SECY-03-0036 subject to the edits of Commissioner Diaz. I completely agree with Commissioner Diaz that the report should be revised to remove two of the events from the list of Abnormal Occurrences. The Energy Reorganization Act defines an Abnormal Occurrence as an "...event which the Commission determines is significant from the standpoint of public health or safety." As pointed out by Commissioner Diaz, in the case of item 02-2 and 02-3, the staff has determined that these events were not significant from the standpoint of public health or safety. They are more appropriately listed in Appendix C.

NOTATION VOTE

RESPONSE SHEET

TO:

FROM:

SUBJECT:

Annette Vietti-Cook, Secretary

COMMISSIONER MERRIFIELD

SECY-03-0036 - REPORT TO CONGRESS ON ABNORMAL OCCURRENCES FOR FISCAL YEAR 2002

Approved X Disapproved Abstain

Not Participating

COMMENTS:

Approved. Concur with the vote of Commissioner Diaz subject to the attached additional edits.

March 25, 2003

DATE

Entered on "STARS" Yes V' No

PREFACE

INTRODUCTION

Section 208 of the Energy Reorganization Act of 1974 (Public Law 93-438) defines an abnormal occurrence (AO) as an unscheduled incident or event that the U.S. Nuclear Regulatory Commission (NRC) determines is significant from the standpoint of public health or safety. The Federal Reports Elimination and Sunset Act of 1995 (Public Law 104-66) requires that AOs be reported to Congress annually. This report discusses those events that the NRC orAgreement State determined were AOs during Fiscal Year 2002. The NRC used the criteria in Appendix A to define AOs for thpurpose t ort. The

criteria were initially promulgated in the NRC policy statement that was pulishe tin the Federal Register on February 24, 1977 (42 FR 10950) followed by . revion q ent yeaý The newest criteria were published in the Federal Register• on April 17-A 997 (62FR-:18Z).

The NRC has determined that, of the incidents and event v e for this reportin!g edod, only those that are described herein meet the AO criteria for bengreported as AOs. The information reported for each AO includes the date and pla, e re and probable consequences, the cause or causes, and actions taken 16 jrevent recurrence.

Appendix A to this report presents the criteria for sel6iiAOs and the h ,denes for selecting "Other Events of Interest." Appendix B contains. tpdatfonreviously' .ported AOs (during FY 2002, there was no significant new inrrrma]ton regardin previousAOs). Appendix C presents information on events that are not ortable rss-asAOs, but ai'e included in the AO report as "Other Events of Interest"based onguidel insprovided by the Commission and listed in Appendix A to this report.., istoricallythe body of the AO report and Appendix C describe events AC)"h. NRC icenseeand Agreement States must report these events to the NRC. - S.--' ,.-.

To disseminatý information •.ki the p the NBC issues a Federal Register notice scbingAorm atiacilities licned or otherwe•'6iregulated by the NRC or an Agreement State.

nformatioon a•tivies hcensed by Agreement States is also publicly available from the Agreement State\ . ,

THE REGULATORY SYSTEM

The system-of licensing and regulation by which the NRC carries out its responsibilities is implemented through the rules a'd regulations in Title 10 of the Code of Federal Regulations (10 CFR). Public participafon is an element of the regulatory process. To-accomplish its object••es, the NRC regularly conducts licensing proceedings, inspection and enforcement actiýities, operating experience evaluations, and confirmatory research, and maintains programs festa~hsh standards and issuing technical reviews and studies.

TheNR adh~eres •to the philosophy that the health and safety of the public are best ensured by establishingmiultiple levels of protection. These levels can be achieved and maintained through regulations specifying requirements that will ensure the safe use of radioactive materials. The regulations contain design and quality assurance criteria appropriate for the various activities

NUREG-0090, Vol. 25xi

Using the criteria and guidelines in Appendix A of this report, the following event that occurred at a U.S. nuclear power plant during this period was significant enough to report as an Abnormal Occurrence (AO):

02-2 Unaccounted for Fuel Pins at Millstone Unit One in Waterford, Connecticut

Appendix A (see Criterion I.C.3, "For All Licensees ") to this report states, in part, that an event will be considered reporting as an AO if it involves a substantiated loss of special nuclear material that is judged to be significant relative to normally expected performance an.Lthat is judged to be caused by a substantial breakdown of the accountability system.

Date and Place - December 14, 2000; Millstone Unit 1, a ded'ommissineboiling water ,,,.reator operated by No ~east Nuclear Eýg e ne t."

"--r Nature and Pr'obable onsequences -On December 1' 2 2000, thq,•icensee orth east•.• Utilities) made a telephone report to the NRC OperationsCenter stating the location o 1t1A fulllength irradiated fuel rods were unaccounted for in the spmcnear material ac~co3ing records. The licensee also submitted a written follow-up Licse i Event Report on January f1, 2001. This issue raised considerable public and media atteion.%•

In 1972, an irradiated fuel assembly with damaged fuel rods was disasembled to allow examination and testing. When the assembly was ecsructed 7 of the fuel rods could not be incorporated in the assembly for longrmstorage. -ThesetwAo fuel rods were therefore put into a fuel rod canister used to st l dated 1979 and 1980 show the fuel rods stored in the canist4 r in the northAestb drof the spent fuel pool, however records created after April 1980.do' not sho•C•the fu ros6r canister in the fuel pool. Significant work, including two reracks-ttd shipmeots of misceii•eous irradiated components from the spent fuel pool, took place J"oA 980to 1992. In.November 2000, a records reconciliation and verification effortindertakei by the licensee to support the sale of the Millstone site to Dominion Resources, determine ethat the location of two full-length irradiated fuel rods was.66t properly reflec~tedn special nucamaterial records.

The licensee fo6red a team to searchtifor the fuel rods and determine how they were misplaced. While the fuel so•lsnwerenot fo•und,the i•ivestigation concluded that the fuel rods were safely located in a acitt lr dispose of radioactive material. The NRC conducted a special inspection from'Obctobe r 9 through December 21, 2001 which determined that the licends' at as thoriough and complete, and the conclusions were reasonable,ahd supportable

Basedlon the staff's knowledge to date, the current risk to human health from the unaccounted for fbei•ods appears to be .insignificant. If the rods are still in the spent fuel pool in an undetermined location (yioich appears highly unlikely based on the licensee's investigations), they would have been-land are subject to all of the controls for protecting workers and the public thýai arein place _foý`dling spent fuel in that area. If the rods were inadvertently shipped offssite4ttheoldhave been packaged in shielded shipping containers due to their high radiatiorjijvels, even if they were mistaken for some other non-fuel component, such as a local

power range monitor, and would therefore have met the requirements for external exposure limits. The licensee's radiation monitoring program would have detected the high radiation levels

NUREG-0090, Vol. 25 5

Fuel Cycle Facilities (Other Than Nuclear Power Plants)

Using the criteria and guidelines in Appendix A to this report, the following event, that occurred at a U.S. fuel cycle facility during this reporting period was significant enough to be reported as an AO:

02-3 Accountability Failure at Nuclear Fuel Services in Erwin, Tennessee

Appendix A (see Criterion l.C.4, 'Theft, Diversion, or Loss of Licensed M~feial,'br Sabotage or Security Breach") to this report states that any substantial breakdiown ofphysical security or material control (i.e., access control containment or accountability systems) fthatignificantly weakened the protection against theft, diversion, or sabota'S ill be considered 6r'rporting as'. an AO. Y &

Date and Place - June 21, 2001, through August 23, 2001 Nucear Fuels Sen.te .... Inc., Erwin, Tennessee

Nature and-Probable Consequences - In June 2001, there w e'severz.failures to follow procedures at Nuclear Fuels Services, Inc. (NFS) thateulte in two co'ntainers of strategic special nuclear material (SSNM) not being recorded in"he li nsee cornpute'rized inventory of material. These two containers remained at the4teinid eecure storgeat all times, but their location was not tracked in the licensee's records syst, rn. lutectd "t -"

On June 22, 2001, two containers of SSN' were ealed wit h tamper-indicating devices (TIDs) and moved from one location to anotherinside a secured mnaterial access area without the appropriate computer transactions.being perfoifed that track and account for the SSNM. Shortly thereafter, the licensee!s material cortro-land -acco unting (MC&A) program identified that two TIDs were•iot with other iinbsed TIDs and copute'r records did not show that they had been used~t'se'a'ISSNM-be ing containers\T6e61icensee searched for the TIDs and, when they coudN'n.tb'e •found, concded tfeihitthey had been lost. On August 10, 2001, the licensee conducted a outine serni-annualphysica•tnventory of the material stored on site and found two containers of SSNMin secure stordge'biKot listed in the inventory records. On August 23, 2001, during theeprscess of ieconcilihngtnhe inventories, the licensee determined that these two containers hadbeen sealed with the missing TIDs and placed in secure storage without the appropriate; computer records being-made. The containers were originally sampled by the operatorhen the items were generated and the samples were sent to the analytical laboratory for When tems were found in the August 2001 inventory, they were open'e6d weighed and sampled again. All measurements matched those initially made. In April 20n2, this material discrpancy came to the NRC's attention, and subsequently, the NRC initiaedthe review of-the event and continued follow-up activities with the licensee.

Thfailure to reccrd the containers had also not been detected by an additional feature of the licensee.sz materI ial control program, referred to as process monitoring. In process monitoring, mass balances are calculated around various process steps, comparing the amount of material put into a process with the amount removed from the process. As a result of errors in records of

NUREG-0090, Vol. 25 8

Nature and Probable Consequence-O •• dip grapher received an

vec thure calculated aa.b7i0 Svy(70 rema he exposure occurredpmeine con uctin "dse-diogriap an mer-sham. _hv ex e device (camera) containin a 1.30

qtth cncl) uob.n1 o-fa radiography so ra cdiog radiorapher starek d at although the camera stio automatic locking mechanism was inthperable whfh enet ng radiora aphy, he did not stopr-d work anceead noteento complete the job its f huhe licenseep hired a consultant to

Atthe gocuside tube Th radiographer ntifed tagaher Radiationeldd ostin

crne c~io c rc ou

hen atme ntuen tdse ral iogran d of t he eqReindiatio ftYhOffvr a s pacnl anct ein

the acexnpsee n of 0 Sv t(ema)did o ah ouhb osd that/r-o te s heiold

whae posibyonuctahed a stend the guiderwent blood fe iorc loated no a rhoemaosr

bliserng othe handasexpeted wicrn otthe souricien forthe s nex Aao h she conadig consureltant study indicated a radiation exposure ranging from 0.70in (70 rposslV e a

(201"rem) exposure.t.the(rightrhm) with

95 percent confidence level. In addition, due diographer's a o

___houe__gra__r dettrminedtthatcthe

reactions , Ta doen calculavint ofteepsr~a ifiut hw oslatdtrie

that a exposure of 0.70 Sv (70 rem) did by ue'c: y A I censee rdiconsp•ultantau tat io oflh

have possibly touched the end of theaguideitube where& ctedsourre pers locater, no erythema or

notitenga clliatr d~ rdigrahi opraios and not s ing iasen. indivi ndua moniutorng

blistering of the hand, as expected with a incidenstee "s yo•e wacited f allo n cnd ulto conducted calculations for a possibl~e Pitmity exposure wihresulted in a possible 2.01 Sv

(201 rem) exposure to the right hanlimits -- icvc e d thn radiographer s failure to:

Caiusra ses It was deter.ined that the cived th (1) wear his al•rming rate meier; aýn,()wa pronlmntrn eie

Actions Tev en i c revent Recurrencep

Licensee -- The lcenseetermiatetheradiographers employment and reviewed the incident with~~ ...... raiorphr.ehooyea 1ý,ihe "c)]•ompany. A licensee consultant evaluation of the

equipment det'8rri•{i'n&'ta~h amera~as functioning properly.

State Aqency -- The licensee •and radiographer were cited for not performing a lockout survey

after a'clt- iographic exposure ý•enot using an alarming rate meter during radiographic operations;

not L!ng a collimator durg radiographic operations; and not using an individual monitoring

devf~e uring radiographic operations. The licensee was also cited for allowing an individual to

rc eive '•an exposure, in ;excess of regulatory limits.

Th elicenseg ha sice terminated its license and the radiographer no longer works in the

"indutril:r•diora p hy industry.

This event is closed for the purposes of this report.

NUREG-0090, Vol. 25 20