Headquarters Daily report JULY 28, 1994 *************************************************************************** REPORT NEGATIVE NO INPUT ATTACHED INPUT RECEIVED RECEIVED HEADQUARTERS X REGION I X REGION II X REGION III X REGION IV X *************************************************************************** PRIORITY ATTENTION REQUIRED MORNING REPORT - REGION JULY 28, 1994 MR Number: H-94-0067 NRR DAILY REPORT ITEM SIGNIFICANT EVENTS EVENTS ASSESSMENT BRANCH DIVISION OF OPERATING REACTOR SUPPORT Subject: MIS-OPERATION OF DC MOTOR STARTING RELAYS The following text is reprinted from Region I Technical Issue Summary RI-94-06, issued on June 22, 1994. Problem: A poorly designed direct-current (dc) motor starting resistance relay led to several instances where the high pressure coolant injection (HPCI) systems for both Peach Bottom units would have been made inoperable. The time armature (TA) relay inserts and then removes steps of resistance to limit the armature starting current on dc motors. Mis-operation of an auxiliary contact on these dc relays caused HPCI system components (motor operated valves and pumps) to fail on demand. This would have prevented the HPCI system from performing its design function. Previous modifications removed the starting resistance function from these relays. However, the auxiliary contacts were left in motor circuits and were still needed to successfully start the motors. Also, the licensee had not evaluated the effect of dc motor starting currents on battery loads, with and without starting resistance. Evaluation: The TA relays in question are Cutler-Hammer model #583 and 687, installed in the Cutler-Hammer, NEMA 2, 250 Vdc motor controllers and in the starting circuits of the HPCI and reactor core isolation cooling (RCIC) systems motors. The relays have one or two contacts which open to place starting resistances into the circuit and close to remove the resistances. In addition, each relay has an auxiliary contact to verify that the TA relay has positioned to put the resistances in the circuit before a motor start. This auxiliary contact must be closed for the motor to start. The resistance bypass contacts on the TA relay are physically independent of the auxiliary contact function. The TA relay auxiliary contact design is poor and has contributed to increased HPCI and RCIC out-of-service times. Peach Bottom experienced four events in which HPCI TA relay auxiliary contacts became misaligned on the contactor. This misalignment occurred when the auxiliary contact plate became loose from a stationary alignment pin and was then free to rotate around the center pivot post. These events have resulted in two auxiliary oil pump (AOP) failures to start on demand and in the failure of two motor-operated valves to operate as required. A modification to the dc control circuits, which removed the starting resistance, left the TA relay auxiliary contact in the circuit for valves on each unit, MO-14 (steam admission, normally closed), MO-20 (outboard injection, normally open), and MO-19 (inboard injection, normally closed). For these valves, the TA relay was only functioning to close its auxiliary contact to energize the motor. The modification was required as the valve actuators did not develop sufficient thrust and torque to perform their required safety function under worst case dc power distribution and environmental conditions. Modifications and temporary modifications to dc circuits were not adequately evaluated with respect to dc bus loads. To resolve the TA auxiliary contact failures, PECO initially jumpered out the TA relay auxiliary contact on the Unit 3 AOP. This allowed the motor to start with the resistance in the circuit but without the verification of the auxiliary contact closure. This temporary modification was subsequently removed when questions of its adequacy with respect to overall battery load were raised (i.e., What would be the effect if the TA relay mis-functioned and the starting resistances were not inserted?). PECO completed an evaluation of dc battery loading and motor starter resistance requirements. PECO determined that the starting resistances are not required for MOVs with maximum torque less than 150 ft-lbs (recommendation from Limitorque). Based on this, temporary modifications were prepared to jumper the auxiliary contacts on all MOV breakers, even if starting resistances were still installed. Battery loading calculations now assume that the starting resistances are not in any MOV circuits. For the auxiliary oil pumps, PECO determined that the starting resistances should be left in the circuit to protect the motor, with the TA auxiliary contact jumpered. In this case, PECO determined that, because the TA auxiliary contacts was not enduring that the resistances were in the circuit, the battery loading needed to be evaluated as if the resistances were not there. This resulted in a situation where under the worst case situation (i.e., starting the system with the normally open MO-20 shut and needing to open) the loading would be unacceptable. To prevent this scenario, PECO has taken administrative actions to ensure that the auxiliary oil pump is taken to pull-to-lock when MO-20 is closed for surveillance testing, with an operator standing by to open MO-20 and start the AOP if needed in an accident situation. Licensee Action: PECO completed modifications that removed the TA relays and starting resistances from all HPCI MOVs at both units. PECO plans a modification to replace the AOP motor controller with a newer design. CONTACTS: Paul Bonnett or Wayne Schmidt (717) 456-7614 Cliff Anderson (610) 337-5227 References: NRC Inspection Reports 50-277 & 50-278/92-27, 93-01, 93-05, 93-25 PRIORITY ATTENTION REQUIRED MORNING REPORT - REGION I JULY 28, 1994 Licensee/Facility: Notification: University Of Pittsburgh MR Number: 1-94-0085 University Of Pittsburgh Date: 07/28/94 Pittsburgh,Pennsylvania Dockets: 03002945 License No: 37-00245-02 Subject: Follow-up of Individual Contaminated with Radioactive Material at University of Pittsburgh Reportable Event Number: N/A Discussion: Region I did a follow-up on the notification from the University of Pittsburgh on June 21, 1994, of the incident involving the contamination, and subsequent medical treatment, of a researcher. The RSO stated that the incident occurred when a researcher was injecting a solution containing 23 microcuries of tin-113 (Sn-113) into an animal. The stopcock in the line became dislodged and approximately 8 microcuries of the solution splashed on the counter and on the researcher's eyes, neck and clothing. The individual's eyes were immediately flushed with water and the individual was taken to an emergency room for an examination and treatment of her eyes. There was no detectable internal intake of the radioactive material by the researcher and the exposure to radiaiton was minimal. The Licensee will submit a written report of the incident to Region I. A PN (PN1-9443) was issued by Region I on June 22, 1994. Contact: Sattar Lodhi (610)337-5364 PRIORITY ATTENTION REQUIRED MORNING REPORT - REGION II JULY 28, 1994 Licensee/Facility: Notification: Florida Power Corporation MR Number: 2-94-0068 Crystal River 3 Date: 07/28/94 Crystal River,Florida Dockets: 50-302 PWR/B&W-L-LP Subject: MANAGEMENT CHANGE Reportable Event Number: N/A Discussion: Effective July 25, 1994, Jerry Campbell will replace Larry Moffatt as Manager, Nuclear Plant Support. Mr. Campbell will be responsible for system engineering, component engineering, inservice inspection (ISI), and the reliability centered maintenance/life cycle management program. He has been with Florida Power Corporation since 1970, and had been Nuclear Shift Manager since 1989. Mr. Moffatt will become a Shift Manager. Regional Action: Issued for information only. Contact: A. LONG (404)331-1464 PRIORITY ATTENTION REQUIRED MORNING REPORT - REGION II JULY 28, 1994 Licensee/Facility: Notification: Babcock & Wilcox Co. MR Number: 2-94-0069 Babcock & Wilcox Co. Date: 07/28/94 Lynchburg,Virginia Dockets: 07000027 License No: SNM-42 URANIUM FUEL FABRICATION Subject: VIOLATION OF NUCLEAR CRITICALITY SAFETY CONTROL FOR HIGH LEVEL DISSOLVER Reportable Event Number: 27592 Discussion: OVER THE PAST TWO YEARS, THE OPERATIONS IN THE BABCOCK & WILCOX NAVAL NUCLEAR FUEL DIVISION URANIUM RECOVERY (UR) AREA HAVE BEEN UNDERGOING MANY CHANGES IN PERSONNEL, OPERATIONAL TECHNIQUES, AND EQUIPMENT CONFIGURATIONS, AND THESE CHANGES ARE CONTINUING. THESE CHANGES HAVE BEEN IMPLEMENTED TO COMPLY WITH THE NEW 10 CFR 20 REQUIREMENTS FOR INTERNAL EXPOSURE TO WORKERS AND AIRBORNE CONCENTRATION IN WORK AREAS. UR PROCESS EFFICIENCY HAS HAD TO INCREASE BECAUSE OF CONTRACT COST REDUCTIONS FROM THE U.S. NAVY. SYSTEM DESCRIPTION UR DISSOLVER OPERATORS HAD RECENTLY BEGUN USING A COMPUTERIZED CONTROL AND TRACKING SYSTEM FOR DISSOLUTION OPERATIONS. THE SYSTEM TRACKS TRAY LOADINGS AND U-235 AMOUNT OF INPUT TO THE SOLVENT EXTRACTION SYSTEM THROUGH DISSOLUTION. NAVAL FUEL ELEMENTS ARE WEIGHED ON A SCALE THAT IS INTERFACED WITH THE COMPUTER SYSTEM. THE COMPUTER SYSTEM KNOWING THE CHEMICAL MAKEUP OF THE NAVAL FUEL DETERMINES THE U-235 CONTENT (AND OTHER CLASSIFIED COMPONENTS) BASED ON THE NET WEIGHT OF THE FUEL ON THE SCALE. THE OPERATOR LOADS THE TRAY AND THE COMPUTER LOGS THE AMOUNT OF U-235 TO THAT PARTICULAR TRAY NUMBER. AFTER DISSOLUTION USING APPROXIMATELY 18 LITERS OF WATER AND ACIDS, A 3ML SAMPLE OF THE SOLUTION IS COUNTED IN A WELL COUNTER. THE MASS OF U-235 IN THE SOLUTION IS CALCULATED BASED ON THE RESULTS OF THE COUNTED SAMPLE. THE U-235 MASS IN THE SOLUTION IS LESS THAN THE TOTAL U-235 MASS LOADED INTO THE TRAY (BECAUSE DISSOLUTION EFFICIENCY IS LESS THAN 100 PERCENT); THEREFORE, A TRAY HEEL INVENTORY IS CREATED AND TRACKED BY THE COMPUTER FOR EACH TRAY. (THE HEEL INVENTORY VALUES ARE AN OVERSTATED AMOUNT OF U-235 BECAUSE SOME OF THE UNDISSOLVED SOLIDS FLOW OUT OF THE TRAY WITH THE SOLUTION AND ARE SUBSEQUENTLY FILTERED BY A CENTRIFUGE BUT THE COMPUTER ASSUMES SOLIDS STATED ARE LEFT IN THE TRAY AS HEEL BY THE COMPUTER.) WHEN ANY PROBLEM OCCURS WITH COMMUNICATION BETWEEN THE SCALE AND THE COMPUTER, A BLINKING ERROR MESSAGE WITH RED BACKGROUND APPEARS ON THE SCREEN (SOME ERRORS CAN BE OF LOWER SAFETY SIGNIFICANCE SUCH AS SCALE MODE IN POUNDS RATHER THAN GRAMS, TARE WEIGHT OF CONTAINERS DID NOT ZERO AFTER WEIGHING, ETC.). THE TRAY OVERLOAD ERROR APPEARS ON THE SCREEN JUST AS ALL OTHER ERRORS. THE PROGRAM ALSO ALLOWS THE OPERATOR TO ACKNOWLEDGE THE ALARM AND CONTINUE WITH THE OPERATION. THE LOCATION OF THE COMPUTER AND THE GLOVE BOX IN WHICH THE FUEL IS LOADED IS SUCH THAT THE OPERATOR CANNOT READ THE COMPUTER SCREEN WHEN STANDING AT THE GLOVE BOX WEIGHING FUEL. WHEN AN ERROR MESSAGE APPEARS ON THE SCREEN, THE OPERATOR CAN SEE THE BLINKING MESSAGE BUT CANNOT READ THE MESSAGE. THE OPERATOR DOES REGION II MORNING REPORT PAGE 2 JULY 28, 1994 MR Number: 2-94-0069 (cont.) HOWEVER HAVE TO ACKNOWLEDGE THE MESSAGE BY PRESSING THE ENTER KEY TO CONTINUE TO THE NEXT TRAY. EVENT AT 7PM ON TUESDAY JULY 26, THE UR FOREMAN NOTICED THAT THE NCS LIMIT OF 500 GRAMS U-235 PER TRAY IN THE HIGH LEVEL DISSOLVER TRAYS #6 OF DISSOLVER BANK FOUR AND NO. 4 OF DISSOLVER BANK TWO HAD BEEN EXCEEDED. AT 10:14AM THE SAME DAY RECORDS INDICATE THAT 51.68 GRAMS U-235 WERE ADDED TO A HEEL OF 451.01 GRAMS U-235 IN TRAY NO. 6 FOR A TOTAL TRAY MASS OF 502.69 GRAMS U-235; AND AT 11:42AM 48.07 GRAMS U-235 WERE ADDED TO A HEEL OF 473.65 GRAMS U-235 IN TRAY NO. 4 FOR A TOTAL TRAY MASS OF 521.72 GRAMS U-235. AFTER DISSOLUTION, THE SOLUTION IN TRAYS WAS RELEASED TO THE MEASUREMENT COLUMNS AND THE HEEL RECALCULATED BASED ON SUBTRACTION OF THE MASS OF U-235 IN THE SOLUTION (DETERMINED BY A WELL COUNT OF A 3ML SOLUTION SAMPLE). THE HEEL INVENTORY OF THE TRAYS INDICATED THAT TRAY #4 CONTAINED 455.12 GRAMS U-235 AND TRAY NO. 6 CONTAINED 490 GRAMS U-235. THE LICENSEE REPRESENTATIVE AFTER REVIEWING AND DISCUSSING THE RECORDS AND MEASUREMENTS WITH MANAGEMENT PHYSICALLY CLEANED THE TRAYS AND WEIGHED THE HEEL AND DETERMINED THE ACTUAL HEEL TO BE 243.2 GRAMS NET WEIGHT OF MATERIAL IN TRAY #4 AND 320 GRAMS NET WEIGHT OF MATERIAL IN TRAY NO. 6. THE LICENSEE THEREFORE CONCLUDED THAT ALTHOUGH THE ADMINISTRATIVE MASS CONTROL FOR THE TRAYS WAS LOST, THE TRAYS NEVER ACTUALLY CONTAINED AMOUNTS OF U-235 GREATER THAN 500 GRAMS. THE MANAGER OF CHEMICAL PROCESSING, THE MANAGER OF SAFETY AND SAFEGUARDS, AND THE MANAGER OF NCS WERE NOTIFIED OF THE MATTER BETWEEN 7:30 PM AND 9:40 PM ON JULY 26. THE DECISION WAS MADE AT THAT TIME THAT OPERATIONS COULD CONTINUE AFTER OPERATORS HAD BEEN RE-INSTRUCTED ON THE NCS LIMITS FOR HIGH LEVEL DISSOLUTION OPERATIONS AND THE NEED TO PAY CLOSE STRICT ATTENTION TO HEEL INVENTORY AND INPUT VALUES. THE LICENSEE IMPLEMENTED CORRECTIVE ACTIONS IMMEDIATELY FOLLOWING THE DISCOVERY OF THE PROBLEM BY RE-INSTRUCTING OPERATORS AT THE BEGINNING OF EACH SHIFT ON NCS LIMITS, USE OF THE COMPUTER SYSTEM, AND ACKNOWLEDGING ALARMS. THE LICENSEE IS CONSIDERING MOVING THE COMPUTER SCREEN CLOSER TO THE GLOVE BOX TO ALLOW THE OPERATOR TO SEE THE SCREEN WHILE WEIGHING FUEL FOR TRAY CHARGES AND MODIFYING THE COMPUTER PROGRAM TO "LOCK UP" NOT ALLOWING THE OPERATOR TO CONTINUE AND FLASH A FULL SCREEN WARNING WHEN THE NCS LIMIT IS EXCEEDED. SAFETY SIGNIFICANCE THE NCS ANALYSIS SHOWS THAT FOR A FOUR INCH SLAB (THE DISSOLVER TRAYS ARE ONLY 3-1/2 INCHES AND ARE FILLED TO AN OPERATIONAL HEIGHT OF 2-1/2 INCHES), AMOUNTS OF U-235 OF UP TO 1800 GRAMS CAN BE LOADED INTO EACH TRAY RESULTING IN A KEFF OF ONLY 0.67. SINCE THE CHEMISTRY OF THE DISSOLUTION OPERATION WILL ONLY ALLOW APPROXIMATELY 50 GRAMS OF U-235 TO BE LOADED INTO A TRAY FOR DISSOLUTION THERE WOULD HAVE TO BE MANY FAILURES OF THE ADMINISTRATIVE CONTROLLED MASS PARAMETERS TO REACH UNSAFE LEVELS. HOWEVER, A SIGNIFICANT PART OF THE EVENT IS THE APPARENT OPERATOR FAILURE TO FOLLOW PROCEDURES, ADHERE TO A NCS LIMIT NO MATTER HOW REGION II MORNING REPORT PAGE 3 JULY 28, 1994 MR Number: 2-94-0069 (cont.) CONSERVATIVE, AND THE NEGATIVE HUMAN FACTORS INFLUENCE ON THE ADMINISTRATIVE CONTROLS. Regional Action: THE SENIOR RESIDENT INSPECTOR IS ONSITE AND IS MONITORING THE LICENSEES ACTIONS REGARDING THIS MATTER. A SECTION CHIEF HAS BEEN SENT TO THE SITE TO ASSIST THE RESIDENT INSPECTOR AND REVIEW THESE RECENT EVENTS. Contact: Edward McAlpine (404)331-5547 PRIORITY ATTENTION REQUIRED MORNING REPORT - REGION IV JULY 28, 1994 Licensee/Facility: Notification: Wolf Creek Nuclear Oper. Corp. MR Number: 4-94-0071 Wolf Creek 1 Date: 07/27/94 Burlington,Kansas Licensee to SRI Dockets: 50-482 PWR/W-4-LP Subject: FITNESS FOR DUTY TERMINATION Reportable Event Number: N/A Discussion: On August 27, 1994, the licensee terminated a permanent employee (health physics technician) after a second positive drug test. The individual had an initial positive test result on March 23, 1989, and had been tested on a followup schedule since that time. The individual provided one of these followup samples on July 20, 1994, and the analysis and reanalysis both identified THC above the regulatory limit. The licensee placed the individual on administrative leave immediately after the initial positive test result on July 23, 1994. The licensee suspended the individual's protected and vital area access on July 23, 1994, and subsequently terminated the employee on July 27, 1994. The licensee initiated a review of the individual's past work to identify whether the fitness for duty issue affected safety or not. Regional Action: The resident inspector and Regional staff will monitor licensee actions. Contact: J. F. Ringwald (316)364-8653