March 5, 2007

EA-07-039NMED No. 060660

Mr. Charles PerkinsSite ManagerAREVA NP, Inc.2101 Horn Rapids RoadRichland, WA 99352-0130

SUBJECT: NRC SPECIAL INSPECTION TEAM REPORT NO. 70-1257/2006-010

Dear Mr. Perkins:

This report refers to the special inspection team (SIT) inspection that included activitiesconducted at the AREVA NP Richland Facility from October 30 through November 2, 2006, thesubsequent in-office review of your evaluation dated December 20, 2006, and teleconferencesconducted with you on November 29, 2006, and January 19, 2007. The purpose of the SIT wasto assess the facts and circumstances surrounding the hydrogen fluoride (HF) leak and theworker exposure on October 23, 2006. A copy of the SIT Charter is included as Enclosure 1. The inspection included a review of your chemical safety operations, plant operations, trainingprograms, and management measures to determine if your facility was operated safely and incompliance with your license.

Areas examined during the inspection are identified in the report. Within these areas, theinspection consisted of a selective examination of procedures and representative records,interviews with personnel, and observation of activities in progress.

The SIT objectives were to: (1) determine the facts surrounding the specific event;(2) determine the safety implications and adequacy of licensee corrective actions; (3) evaluatethe licensee’s response to the event; (4) assess the licensee’s activity during the event reviewand recovery; and (5) identify the root causes.

The SIT determined that the event’s immediate safety consequences were limited to a workerthat incurred a short duration HF exposure. The air concentration to which the worker wasexposed was less than the federal limits (30 parts per million (ppm)) considered as immediatelydangerous to life and health (IDLH), which would cause irreversible health effects if exposed for30 minutes or more without proper respiratory protection equipment. The controls that were inplace to prevent an intermediate consequence event and alert personnel to prevent an acuteexposure to HF and alert workers to flee the area were inadequate for HF concentrations lessthan or equal to 30 ppm. There also appeared to be a lack of rigor for following proceduresassociated with event notification and reporting to plant management and health and safetypersonnel.

C. Perkins 2

The SIT concurs with your Root Cause Analysis (RCA) and contributing factors surrounding theevent as discussed in your letter dated December 20, 2006. Corrective actions that wereimplemented or planned were determined to be adequate. Based on the results of thisinspection, the SIT has identified apparent violations (APVs) of NRC requirements and arebeing considered for escalated enforcement action in accordance with the NRC EnforcementPolicy.

The current Enforcement Policy is included on the NRC’s Web site at www.nrc.gov; selectWhat We Do, Enforcement, then Enforcement Policy.” The APVs discussed inParagraph 2.a of this report involved the failures in event reporting, inappropriate respiratoryprotection equipment, and inadequate Items Relied On For Safety (IROFS) for a small HFrelease. The circumstances surrounding these APVs, the significance of the issues, and thestatus of effective corrective actions were discussed with members of your staff on January 19,and February 1, 2007.

Before the NRC makes its enforcement decision, we are providing you an opportunity to either:(1) respond to the APVs addressed in this inspection report within 30 days of the date of thisletter or (2) request a predecisional enforcement conference. If a conference is held, it will beopen for public observation. The NRC will also issue a press release to announce theconference. Please contact David Ayres (404-562-4711) or Al Gooden (404-562-4716) withinseven days of the date of this letter to notify the NRC of your intended response.

If you choose to provide a written response, it should be clearly marked as a "Response toApparent Violations in Inspection Report No. 70-1257/2006-010; EA-07-039" andshould include for each apparent violation: (1) the reason for the apparent violation, or, ifcontested, the basis for disputing the apparent violation; (2) the corrective steps that have beentaken and the results achieved; (3) the corrective steps that will be taken to avoid furtherviolations; and (4) the date when full compliance will be achieved. "In presenting yourcorrective actions, you should be aware that the promptness and comprehensiveness of youractions will be considered in assessing any civil penalty for the apparent violation(s). Theguidance from NRC Information Notice 96-28, "Suggested Guidance Relating to Developmentand Implementation of Corrective Action," may be helpful." Your response may reference orinclude previously docketed correspondence, if the correspondence adequately addresses therequired response. If an adequate response is not received within the time specified or anextension of time has not been granted by the NRC, the NRC will proceed with its enforcementdecision or schedule a predecisional enforcement conference.

In addition, please be advised that the number and characterization of apparent violationsdescribed in the enclosed inspection report may change as a result of further NRC review. Youwill be advised by separate correspondence of the results of our deliberations on this matter.

In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter and itsenclosures will be made available electronically for public inspection in the NRC PublicDocument Room or from the NRC’s document system (ADAMS), accessible from the NRCWeb site at http://www.nrc.gov/reading-rm/adams.html.

C. Perkins 3

Should you have any questions concerning this letter, please contact us.

Sincerely,

/RA/

Douglas M. Collins, DirectorDivision of Fuel Facility Inspection

Docket No. 70-1257License No. SNM-1227

Enclosures: 1. SIT Charter w/attachment2. NRC Inspection Report

cc w/enclsThomas Scott Wilkerson, Vice President, EngineeringAreva NP3315 Old Forest RoadLynchburg, Virginia 24501

Ron Land, Vice President, ManufacturingAreva NP2101 Horn Rapids RoadRichland, Washington 99352

Robert E. Link, ManagerEnvironmental, Health, Safety & LicensingAreva NP2101 Horn Rapids RoadRichland, Washington 99352

Loren J. Maas, ManagerLicensing and ComplianceAreva NP2101 Horn Rapids RoadRichland, Washington 99352

Calvin D. Manning, ManagerNuclear Criticality SafetyAreva NP2101 Horn Rapids RoadRichland, Washington 99352

cc w/encls: (Cont’d on page 4)

C. Perkins 4

(cc w/encls: continued)Gary L. Robertson, DirectorDivision of Radiation ProtectionDepartment of Health, Bldg 5PO Box 478277171 Cleanwater LaneOlympia, Washington 98504-7827

Distribution w/encls:J. Strosnider, NMSSW. Travers, RIIR. Pierson, NMSSD. Ayres, RIIA. Gooden, RIIN. Baker, NMSSM, Adams, NMSSM. Galloway NMSSOEMail

G PUBLICLY AVAILABLE G NON-PUBLICLY AVAILABLE G SENSITIVE G NON-SENSITIVE

ADAMS: G Yes ACCESSION NUMBER:_________________________

OFFICE RII:DFFI RII:DFFI RII:DFFI RII:DRS RII:DFFI NMSS RII:EICS

SIGNATURE /RA/ AGooden for /RA/ /RA/ /RA/ A Gooden for /RA/NAME AGooden OLopez SSubosits EMichel DAyres NBaker CEvans

DATE 02/27/2007 02/23/2007 02/27/2007 03/02/2007 03/05/2007 02/27/2207 March 8, 2007

E-MAIL COPY? YES YES NO YES NO YES YES NO YES NO YES NO

OFFICIAL RECORD COPY DOCUMENT NAME: C:\FileNet\ML070650158.wpd

Enclosure 1

Special Inspection CharterAREVA NP, Inc.

Hydrogen Fluoride (HF) Exposure

Basis

On Monday, October 23, 2006, two workers entered the dry conversion process area and notedan unusual odor. Upon discovery of this condition, workers immediately evacuated the area. The workers obtained respiratory protection and returned to the process area for collecting airsamples. Samples were collected for both chemical and radioactive determination to assist inthe identification of what may have been leaking and the location for leak. During chemicalsampling using a draeger gas collection instrument, it was observed that HF levels in the vicinityof the conversion line 3 reactor was 30 parts per million (ppm). No elevated radiationmeasurements were recorded. The leak was determined to be a hair-line crack within the weldaround a plug on the reactor off-gas system. Line 3 operations were terminated and actionswere initiated to inspect weld joints on the second of two reactors for line 3 and otherassociated line 3 process equipment to verify that there was no breach of containment, orsignificant physical damage. Lines 1 and 2 were subsequently shutdown for examination.

The workers were unaware of the HF release at the time of the initial entry to the process area. As a result, a short duration exposure to HF occurred. No reports or requests were filed withsite health and safety personnel to assess the significance of the employees exposure orphysical condition. The workers did not experience any immediate effects from the exposure.However, after arriving at home from shift work, one of the workers complained to his wife thathe was experiencing a tingling sensation and physically did not feel well. In response, theindividual was transported to the hospital by his wife and remained hospitalized untilWednesday, October 25, 2006.

Scope

In order to develop the safety significance of the event, the team should focus on the areaslisted below. They are listed in order of importance.

1. Develop a complete sequence of events related to the event.

2. Identify and evaluate the effectiveness of the immediate corrective actions taken by thelicensee in response to the event.

3. Evaluate the potential for an acute chemical exposure to HF at the time of discovery bythe workers. This should consider the sequence of events following the recognition byworkers of an unusual odor (how long in the area without personal protective equipment,was the proper equipment used for sampling the environment, was the workers properlytrained on how to use the Draeger equipment, and did workers follow reportingprocedures).

4. Evaluate the risk significance to other workers, the public, and environment.

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5. Review and evaluate the licensee’s root cause analysis for adequacy of scope, depth,and identification of causal factors.

6. Evaluate the adequacy of the licensee*s response. Determine adequacy of internal andexternal licensee event reporting. This should include a review of the informationavailable to the licensee to use as indicators of a problem, timeliness of reporting tooffsite agencies (NRC, OSHA, State, DOL) and the response to safety issues. Safetyissues include chemical and radiological areas.

7. Determine the probable contributing and root causes for the failure to perform anassessment of the worker’s health following the exposure.

8. Evaluate the adequacy of the licensee’s training program and procedures for respondingto HF events.

9. Determine the adequacy of the licensee’s actions to prevent recurrence.

10. Determine to what standard the chemical reactor vessel was constructed (i.e. ASMEBoiler and Pressure Vessel Code). Determine the adequacy of any maintenancerequirements for the chemical reactor vessel and/or periodic-in-service inspectionprogram that check the welds for flaws.

Documentation

Document the inspection findings and conclusions in an inspection report within 30 days of thecompletion of the inspection.

October 27, 2006

MEMORANDUM TO: Alphonsa Gooden, LeaderAREVA NP Special Inspection Team

FROM: William D. Travers, Regional Administrator

SUBJECT: SPECIAL INSPECTION TEAM CHARTER FOR AREVA NP RICHLAND,DOCKET NO. 70-1257 (INSPECTION REPORT NO. 70-12657/2006-010)

This memorandum confirms the establishment of a Special Inspection Team to inspect andassess the facts and circumstances of the hydrogen fluoride leak and worker exposure. Theevent occurred on October 23, 2006 (Event # 42936) and was reported to the NRC OperationsCenter on October 26, 2006 (21:09 EST). You are the team leader and should report statusdirectly to me. Your team members are: M. Baker (NMSS), O. Lopez (RII), S. Subosits (RII),and E. Michel (RII).

The inspection and report will be performed in accordance with the guidance of InspectionProcedure (IP) 88003, and the applicable provisions of IP 93812, and will be consistent withManagement Directive 8.3 and Manual Chapter 2600. The report will be issued within 30 daysof the completion of the inspection.

A copy of the Charter is enclosed for your use. The objective of the team is to gatherinformation and make appropriate findings and conclusions in the areas listed in the Charter. These will then be used as a basis for any necessary followup. As indicated in the Charter, theforemost objective is to determine the safety implications and adequacy of licensee correctiveactions for the sequence of events which resulted in the workers exposure to HF release.

If you have any questions, please contact me.

Enclosure: Special Inspection Charter

cc w/encl:W. Travers, RIIJ. Strosnider, NMSSR. Pierson, FCSSD. Ayres, RII

Attachment

Enclosure 2

U.S. NUCLEAR REGULATORY COMMISSION

REGION II

SPECIAL INSPECTION TEAM

Docket No.: 70-1257

License No.: SNM-1227

Report No.: 70-1257/2006-010

Licensee: AREVA NP, Inc.

Facility: Richland Facility

Location: Richland, WA 99352

Dates: October 28 - January 19, 2007

Inspectors: A. Gooden, Team Leader (RII)M. Baker, Project Manager (NMSS)O. Lopez, Fuel Facilities Inspector (RII)S. Subosits, Fuel Facilities Inspector (RII)E. Michel, Reactor Inspector (RII)

Approved by: D. Collins, DirectorDivision of Fuel Facility Inspection

EXECUTIVE SUMMARY

AREVA NP, Inc.NRC Inspection Report 70-1257/2006-010

The purpose of the Special Inspection Team (SIT) was to review and assess the facts andcircumstances of the hydrogen fluoride (HF) leak and worker exposure event of October 23,2006, to determine the safety implications and the adequacy of licensee corrective actions. TheSIT objectives were to: (1) determine the facts surrounding the specific event; (2) determine thesafety implications and adequacy of licensee corrective actions; (3) assess the licensee’sresponse to the event; (4) assess the licensee’s training program and procedures forresponding to HF events; and (5) identify the root causes.

Event Description

Around 10:50 a.m. on October 23, 2006, a Conversion Technician (CT) noted an unusual odorwhile performing a routine process area walk-down on the fourth level of the dry conversionroom and discussed the odor with a nearby Health and Safety Technician (HST). The CT andHST immediately evacuated the area and posted the area as radiological respiratory protectionrequired. The CT and HST departed the area to obtain respiratory protection equipment. TheCT and HST returned to the process area to perform air sampling to identify the source of theodor. The CT determined that the odor was due to HF. The CT discussed the results with theDC Control Room and it was determined that self-contained breathing apparatus equipment(forced air) should be worn during re-entry to area. No elevated radiation measurements wererecorded. Based on the air sampling results, the HST was instructed to post the area asrequiring full face mask for gases and vapors. Around 11:25 a.m., the CT closed the valvescontrolling UF6 gas flow to conversion and the control room operators shut down Line 3 andinitiated a condition report for the incident. At home that evening, the CT did not feel well andwas subsequently hospitalized for HF exposure and a 48-hour observation until discharged onOctober 25, 2006.

Event Assessment

The licensee’s controls to prevent worker exposure to HF vapors were inadequate. Theinspectors’ assessment of the event identified the following apparent violations:

! Failure to obtain the appropriate respiratory protection equipment in accordance withManagement Control Procedures 30102 and 30036.

! Failure to notify onsite personnel in accordance with Standard Operating Procedures40486, 40228, and Environmental Health, Safety and Licensing Procedure E18-01-002.

! Failure to meet the performance requirements of 10 CFR 70.61(c)(4)(i) to prevent ormitigate an acute, intermediate-consequence chemical exposure from HF release thatcould have lead to irreversible or other serious, long-lasting health effects.

! Failure to notify NRC in accordance with 10 CFR 70 Appendix A(b)(1).

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Root Causes and Contributing Factors

The inspectors concluded that the licensee’s analysis and identification of root and contributingcauses and inappropriate actions which led to the failure of the conversion reactor andsubsequent leak of HF was satisfactory. The inspectors concluded that the licensee hasadequately identified causal factors in their Apparent Cause Analysis (ACA) and takencorrective actions to ensure a more effective organizational response to unusual events. Theinspectors also determined that the licensee’s identification of causal factors/inappropriateactions in their ACA along with the corrective and preventive actions taken to preventrecurrence were satisfactory to ensure timely reporting.

The direct cause of the leak was an inadequate weld on an inspection plug on the V3-303reactor vessel plenum.

The root cause of the leak was identified as the manufacturer’s failure to fabricate the vessel’splenum per the approved original drawing in the time frame of February 1996 - May 1997.

The root cause of the failure by the operations supervision to notify EHS&L of the HF leak, andthe failure of first line EHS&L supervision to perform a reportability evaluation of the HF leak,was due to less than adequate communications and a failure to adhere to proceduralrequirements for reporting of abnormal or unusual events.

The root cause of the failure to report the event in a timely manner to the NRC in accordancewith 10 CFR 70 Appendix A (b)(1) was the result of the EHS&L manager incorrectly assumingthe HF leak event was covered by the existing ISA for the dry conversion process and did notrepresent an unanalyzed accident scenario.

Assessment of Licensee’s Investigation and Corrective Actions

The CT and HST responded promptly to the release by evacuating the area, posting to preventpersonnel entry without wearing respiratory protection equipment, and collecting samples toidentify what was leaking, the source of the leak, and area impacted. However, the properrespiratory protection to be used was not initially identified. Operations involving Line 3 wereshutdown pending an investigation into what may have caused the leak.

Attachment:Partial List of Persons ContactedList of Inspection Procedures UsedList of Items Open/ClosedList of Acronyms Used

REPORT DETAILS

1. Event Description (NRC Event No. 42936)

The event description was independently developed and validated by the inspectorsusing a review of records, Dry Conversion Facility (DCF) logs and interviews withpersonnel directly involved with activities prior to and during the hydrogen fluoride (HF)release.

Around 10:50 a.m. on October 23, 2006, a conversion technician (CT) performing aroutine process area walk-down on the fourth level of the dry conversion room noted anunusual odor. As the CT proceeded north past one of two Line 3 reactor vessels, theodor became stronger. When the CT moved in a south westerly direction, the odor wasno longer noticed. The CT observed a health and safety technician (HST) entering thearea to perform routine radiation protection activity and asked the HST if an unusualodor was noticed. In response, the HST indicated that no odor was detected but asensation similar to an oncoming sneeze was felt. Both the CT and HST indicated thatthere was no visual indications of the presence of a gas or vapor. Upon discovery ofthis condition, both the CT and HST immediately evacuated the area and posted thefourth floor as an area requiring respiratory protection.

The CT obtained a full-face mask with a combination type cartridge (particulate and gasvapor) and the HST returned with a full-face type H (radioactive particulate only)respirator to the process area for collecting air samples for both chemical andradioactive determination to assist in the identification of what may have been thesource of the leak and the leak location. The CT pulled several samples which weretaken to the DCF Control Room for evaluation. Based on the evaluation andconfirmation of elevated levels of HF, the DCF Control Room requested the CT don self-contained breathing apparatus equipment (forced-air) for re-entry. The CT re-enteredthe area wearing the appropriate respiratory protection and observed that the maximumHF levels in the vicinity of the conversion Line 3 reactor was 15-20 parts per million(ppm). No elevated radiation measurements were recorded by the HST. Based on theelevated HF levels, the Control Room operators commenced shut down of conversionLine 3 and initiated a condition report for the incident.

2. Event Assessment

a. Inspection Scope and Observations

The inspectors interviewed the CT and HST who initially discovered the situation,Conversion Shift Supervisor, Chemical Operations Technician, HST Supervisor,Environmental Health, Safety and Licensing (EHS&L) personnel, emergencymanagement personnel, and site management in order to evaluate the adequacy of theinitial actions taken by technicians, operators, supervisors, and management to the HFrelease.

Based on interviews and a review of the DCF log, a “hot metal odor” was noted by theCT and approximately two minutes later, an HST in the area performing routineradiological activity was questioned by the CT regarding the odor and the HST

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acknowledged a sneeze-like sensation (but no odor, visible cloud or smoke). Inresponse, the CT and HST immediately evacuated the area and posted area asrespiratory protection required. The CT indicated that total time from detection of a “hotmetal odor” to evacuation was less than three (3) minutes. Considering that there wasno audible or visual indications that a release was occurring, the decision to evacuateand post the area was both timely and appropriate. However, the area was initiallyincorrectly posted as an area requiring respiratory protection for radiological rather thanchemical (HF) exposure. Following evacuation, the CT and HST discussed the need tocollect air samples from the vicinity of line three. The CT discussed the odor that wasdetected and the location with the DCF Control Room. The Control Room requestedthat the CT conduct Draeger tube measurements on the fourth level of the dryconversion room. The CT and HST promptly reported to the HST office to obtainrespiratory protection equipment and returned to conduct air sampling from the dryconversion room.

The inspectors determined that the HST originally thought that the odor may have beendue to a radiation release and was unaware of the HF hazard potential for the incidentarea. Thus, he responded to collect air samples using respiratory protection appropriatefor a radiological rather than a chemical hazard. The CT selected a full-face mask withcombination cartridges that provided protection for both radioactive and chemicalenvironment, but would only provide protection for HF concentrations of less than30 ppm. The inspectors reviewed the licensee procedures for issuance and use ofrespiratory protection. Section 6.1 of procedure Management Control Procedure(MCP)-30102 required using only self-contained breathing apparatus in the positivepressure or pressure demand mode for UF6 or unidentified vapor releases. Table II ofMCP-30036 listed the required types of respirators for use in HF concentrations rangingfrom 3-30 ppm (full-face chemical cartridge) and concentrations greater than 30 ppm(self-contained pressure-demand breathing apparatus with full-face mask or pressure-demand airline with full-face mask and egress provisions). The inspectors determinedthat the respiratory protection equipment was not provided to the HST or the CT inaccordance with licensee procedures. Failure to obtain respiratory protection equipmentin accordance with procedures was identified as an Apparent Violation (APV) (APV 70-1257/2006-010-01).

The HST and CT made independent decisions regarding personal protective equipmentneeds without consulting immediate supervisors and/or health and safety management. The incorrect posting and respiratory protection equipment also resulted from the lack ofcommunications with supervisory personnel by both the CT and HST. The inspectorsdetermined that the lack of communications with supervisory personnel was inconsistentwith requirements in the Standard Operating Procedures (SOPs). SOP 40486 (RichlandOperations General Rules, Section 5.5) and SOP 40228 (Chemical Operations Rules,Section 10.9) required personnel to immediately report any unusual events or spills tothe Supervisor. In addition, Section 4.1 of Procedure E 18-01-002 required immediatenotification of the EHS&L staff in the event of a radiation or chemical release orexposure that could affect the health of individuals onsite or offsite. The first notificationto EHS&L staff did not occur for more than 30 minutes after the event andapproximately 20-25 minutes after the maximum HF reading was measured. Both theCT and HST failed to immediately report the unusual event to their supervisors in

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accordance with licensee procedures. The failure to immediately report this event tosupervisory/management personnel was identified as an APV (APV 70-1257/2006-010-02).

The inspectors reviewed the licensee’s integrated safety analysis (ISA) and associatedsafety controls and determined that the Items Relied On For Safety (IROFS) listed forthe vaporization and conversion areas were designed for UF6 leaks. The controlsincluded vessel integrity, installed smoke detectors, a see and flee policy for vaporclouds, and obtaining first aid in the event of a chemical exposure. The inspectorsdetermined that these controls were inadequate to ensure that a significant exposure toHF vapors would be unlikely. The licensee’s controls associated with liquid HF spillsalso did not address the hazards associated with this event. Exposure to HF at thelevels measured and reported by the CT was characterized as an event of potentialintermediate consequence (see Section 4). The inspectors determined that the licenseefailed to meet the performance requirements in 10 CFR 70.61(c) in that controls werenot adequately applied to the extent needed such that an intermediate-consequenceevent was unlikely to occur or was mitigated. Failure to meet the performancerequirements in 10 CFR 70.61(c)(4)(i) was identified as an APV (APV 70-1257/2006-010-03).

The inspectors found that once notified of the event, licensee management did notrecognize that this event involving a HF vapor leak in the DCF resulted in a conditionthat was different from the events analyzed in the ISA for UF6 leaks or HF liquid spills. In addition, licensee management did not recognize that the performance requirementsof 10 CFR 70.61 were not being met. Consequently, the facility was operating in a statethat was different from that analyzed in the ISA, and that resulted in the failure to meetthe performance requirements of 10 CFR 70.61. Appendix A of 10 CFR Part 70 statesthat the combination of these conditions require the event be reported to the NRCOperations Center within 24 hours of discovery. However, the event was not reporteduntil October 26, 2006, following conversations with NRC inspectors onsite and withNRC management by phone. Therefore, the failure to notify NRC in accordance withthe timeliness requirements of 10 CFR Part 70 Appendix A(b)(1) was identified as anAPV (APV 70-1257/2006-010-04).

The Manager, EHS&L expressed disagreement regarding this being a reportable event. The licensee believed that the event was bounded by accident sequence 810-5 of theISA involving the UF6 vaporization process system. He also disagreed with theinspectors’ assessment that the event constituted an acute chemical exposure thatcould lead to serious health effects because of the actual conditions of exposure to theHST (the measured HF concentration was less than 30 ppm and the duration ofexposure was five minutes or less total time). Thus the licensee also believed that theydid not fail to meet the performance requirements of 10 CFR 70.61(c).

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b. Conclusions

The licensee’s controls to prevent worker exposure to HF vapors were inadequate. Theinspectors’ assessment of the event identified the following APVs:

! Failure to obtain the appropriate respiratory protection equipment in accordancewith MCPs 30102 and 30036.

! Failure to notify onsite personnel in accordance with SOPs 40486, 40228, andEHS&L Procedure E18-01-002.

! Failure to meet the performance requirements of 10 CFR 70.61(c)(4)(i) toprevent or mitigate an acute, intermediate-consequence chemical exposure fromHF release that could have lead to irreversible or other serious, long-lastinghealth effects.

! Failure to notify NRC in accordance with 10 CFR 70 Appendix A(b)(1).

3. Effectiveness of Immediate Corrective Actions

a. Inspection Scope and Observations

The inspectors conducted interviews and reviewed documentation to determine theadequacy of the licensee’s immediate response and corrective actions to the HF releaseof October 23, 2006. The decision by the CT and HST to immediately evacuate thearea and post as “respiratory protection required to enter” was appropriate to minimizeexposure consequences and protect other conversion workers from potential HFexposure. However, the proper respiratory protection to be used was not initiallyidentified. When additional information was available from the air samples verifying thepresence of HF, the area posting and the personal protective equipment (PPE)requirements were revised as appropriate for the HF chemical hazard, and the ControlRoom initiated the shutdown of the affected conversion line (Line 3) to remove thesource term of the leak.

b. Conclusions

The CT and HST responded promptly to the release by evacuating the area, posting toprevent personnel entry without wearing respiratory protection equipment, and collectingsamples to identify what was leaking, the source of the leak, and area impacted. However, the proper respiratory protection to be used was not initially identified.Operations involving Line 3 were shutdown pending an investigation into what may havecaused the leak.

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4. Chemical Exposure to Hydrogen Fluoride (HF)

a. Inspection Scope and Observations

The inspectors reviewed the DCF control room shift log book, and conducted interviewswith the Conversion Shift Supervisor, CT and HST who initially observed the unusualodor, the HST Supervisor, members of the EHS&L staff, and site management. Theinterviewees all acknowledged that a short duration HF release occurred and the CTand HST were in the area at the time of the release. The CT estimated that he was inthe area for less than a minute after smelling an unusual odor before leaving to obtainrespiratory protection.

The CT and HST collected air samples for both chemical and radioactive analysis toassist in the determining the source and location of the leak. The CT collected severalsamples from various locations within the DCF which were taken to the DCF ControlRoom for evaluation. The CT stated that HF concentrations of approximately 7 ppmwas measured at the north end of reactor vessel V3-303 and greater than 15 ppm weremeasured at V3-303, in the northwest corner of the building. According to interviewee,measurements were made at other locations within the DCF but no HF was detected. The CT stated that a total of five samples were taken to the DCF control room forobservation and confirmation of results. Based on the evaluation and confirmation ofelevated levels of HF, the control room requested the CT don self-contained breathingapparatus equipment (forced-air) for re-entry and additional sampling. The buildingposting was also revised to require respiratory protection against chemical rather thanradiological hazards. When the inspectors asked for the survey documentation forreview, the inspectors were informed that the survey results were not documented bythe CT or DCF Control Room personnel.

Since the concentration of HF vapor was measured using a Draeger tube, the exact HFconcentrations in the area can not be exactly determined. Draeger tube measurementsare affected by the technique used and the interpretation of the results. Also, since theexact location of the leak was not known when the Draeger tube measurements weretaken, higher concentrations than those measured were possible closer to the source ofthe leak. The CT initially stated that the maximum HF levels measured in the vicinity ofthe conversion Line 3 reactor were 15-20 ppm. Interviews with DCF operators indicatedthat the Draeger tube measurement showed a maximum HF concentration greater than20 ppm. The CT later re-interpreted the Draeger tube readings and indicated that themaximum measurement was 15 ppm. The CT indicated that the maximum total timespent during the performance of the routine walk-through of the fourth floor areas andthe subsequent collection of air samples was less than five minutes.

The CT stated that the sensation in his nose and throat did not decrease during the10 hours following the incident. The CT was treated at a local hospital and held forobservation for a period of 48 hours (October 23 - 25). The HST indicated that heexperienced no irritation or medical issues following the event. The CT time in the areaof the leak exceeded that of the HST and resulted in a short duration exposure to HF. Limits for exposure to HF are based on concentration and exposure time, with higherconcentrations being limited to shorter allowed exposure times. The OSHA-allowable

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concentration for an 8 hour exposure is around 3 ppm while concentrations above about50 ppm are considered life threatening at even brief exposures. The NIOSH limit of30 ppm is considered immediately dangerous to life and health (IDLH) and would causeirreversible health effects if exposed for 30 minutes or more without proper respiratoryprotection equipment. Since the measured concentration for this event was around 15-20 ppm, and controls were effective to limit the exposure of the worker, this wasconsidered a potential intermediate-consequence event as defined in 10 CFR 70.61(c).

b. Conclusions

The inspectors confirmed that a short duration exposure to HF occurred to the CT. Theleak of HF vapor at the concentration measured was considered a potentialintermediate-consequence event.

5. Risk Significance to Other Workers, Public, and Environment

a. Inspection Scope and Observations

Based on the inventory of material inside the reactor vessel, a sufficient quantity of HFwas available such that an atmosphere could have existed which would have levels ofHF considered immediately dangerous to life or health for a nearby worker. Althoughsurvey documentation was lacking, based on the interviews and the locations wherepositive readings were measured, the release and area of impact was localized andimpacted only individuals in the vicinity of Line 3. Thus the risk was limited to theworkers in the immediate area and characterized as potential intermediate consequenceevent as defined in 10 CFR 70.61(c). There was no significant risk of a release to thepublic, environment, or workers elsewhere within the facility.

b. Conclusions

Although survey documentation was lacking, based on the interviews, and the locationswhere positive readings were measured, the release and area of impact was localizedand impacted only individuals in the vicinity of Line 3. There was no release to thepublic, environment, or workers elsewhere within the facility.

6. Root Causes, Contributing Factors and Corrective Actions

a. Inspection Scope and Observations

The inspectors interviewed licensee management and staff regarding the event, andduring the site visit, monitored the performance of the licensee’s investigative teams. Following the site visit, the team received status reports on the licensee’s investigativeteam results and corrective actions prior to resuming operations in the DCF. OnDecember 20, 2006, the licensee completed their root cause analysis (RCA) of the HFvapor leak in the DCF and transmitted the RCA to the NRC for review and evaluation. Along with this transmittal, the licensee also provided two apparent cause analyses(ACAs) for NRC review. One ACA team investigated the response of the licensee’sorganization to the HF vapor leak. The second ACA team investigated the actions of

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the licensee’s organization following the event that resulted in the licensee not reportingthe HF vapor leak event internally or externally in a timely manner. The inspectorsreviewed the licensee’s RCA and ACA for adequacy of scope, depth, and identificationof causal factors.

The licensee formed a team to determine root and contributing causes of the HF leakfrom dry conversion reactor V3-303 and recommend corrective actions to preventrecurrence. Prior to the conclusion of the site inspection, the licensee had identified thedirect cause of the leak as an inadequate weld on an inspection plug on the V3-303reactor vessel plenum (See Figure 1). In addition, the licensee’s root cause analysislater identified the manufacturer’s failure to fabricate the vessel’s plenum per theapproved original drawing in the time frame of February 1996 - May 1997 as a rootcause. Specifically, the licensee concluded that the manufacturer added a fillet weldbetween the inconel threaded plate for the inspection plugs and the monel plenum bodyplate to ensure the vessel did not leak. The licensee’s RCA team determined that thisadditional weld distorted the threaded plug hole on V3-303 and an inappropriate actionon the part of a project engineer followed in May 1997 when the vessel was acceptedwith the seal weld without any verification of impacts to the vessel integrity. Followingthe May 1997 arrival of the V3-303 reactor at the Richland Site, the threaded plugs forinspection were installed during startup of the DCF. The licensee’s RCA teamconcluded that at this point in the project, a plug in V3-303 was incompletely inserted,and an exterior seal weld was subsequently applied to form the pressure boundary. Thelicensee’s RCA determined that the licensee’s oversight of construction activities at thetime of the construction of the DCF was less than adequate and resulted in the additionof the seal weld at the plug without an engineering analysis to demonstrate its adequacyas a pressure retaining weld. The RCA also noted the inspection plug was inserted nomore than one thread deep, and as a result it extended well beyond the end of thevessel plenum, and interfered with the nut on one of the vessel bonnet studs (Figure 2). The licensee believed the physical position of the plug combined with the thermalcycling of the reactor vessel placed stress on the exterior seal weld around theinspection plug. This condition was identified as a contributing cause to the vesselfailure resulting in the HF leak.

Figure 1. Showing V3-303 Leak Locations

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Figure 2. Showing the contact between the flange stud nut and the pipe plug. Asmaller height nut is shown for reference

Prior to resuming operations, the licensee examined the extent of condition in the DCF.Specific actions taken by the licensee were: (1) inspected all reactors and removed allpotential interferences from bolted components, and (2) inspected and smoke testedother mechanical flanges on the vessels and offgas system. The corrective actionstaken or planned to be taken included an evaluation of the configuration control programprocedure to address weaknesses in construction project oversight for field changes toequipment, creation of HF Awareness training for personnel assigned to the dryconversion facility, and an update to appropriate plant nodes in the ISA and criticalitysafety documentation to ensure HF-only leak accident scenarios are identified withappropriate IROFS. As an additional preventive measure, the licensee installed HFdetectors with warning lights in the DCF to ensure timely detection and warning of HF-only leaks. The inspectors determined the RCA was adequate in identifying causalfactors and the corrective actions identified in the RCA were adequate to preventrecurrence of an HF vapor leak in the DCF.

The licensee’s staff performed an ACA for CR-4816 to evaluate the response of thelicensee’s organization to HF vapor leak event. One product of this analysis was adetailed timeline of events throughout the incident. In addition to the timeline, thelicensee identified inappropriate actions or missed opportunities by personnel during thecourse of the event, including the failure to report abnormal conditions associated withthe HF leak to supervisors in a timely manner, initial incorrect posting of respiratoryprotection requirements, plant personnel’s lack of awareness of the potential for an HFleak in the DCF, initial inappropriate respirator selection by the HST involved in theresponse to the HF leak, and inadequate evaluation and consultation with the CT on theneed for medical treatment. In regards to CT’s initial response to the unusual odor nearreactor V3-303, the inspectors noted that the licensee’s analysis identified the operator’smindset as a contributing cause based on routine daily walkthroughs into the dryconversion reactor area. The repetitive nature of the routine walkthrough may have ledthe operator to continue along his normal walking path even when presented with anabnormal condition in the form of an unfamiliar odor. In addition, the lack of training andfamiliarity with the attributes of an HF-only release was a contributing cause to theoperator not recognizing the odor as there had been no prior occurrence of an HF-only

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release in the DCF. An HF release, unlike a UF6 release, does not produce a visiblevapor cloud upon discharging to the atmosphere. The inspectors determined that thelicensee’s identification of inappropriate actions in the ACA for CR-4816, adequatelycaptured the contributing causes that resulted in a less than adequate response bylicensee personnel to an unusual event. The preventive actions identified by thelicensee included HF awareness training for personnel at risk to HF exposure in the dryconversion facility, and upgrades to the respirator issuance program to ensurerespirators issued are adequate for the hazard present. The licensee also hascommitted to upgrade operations procedures and training to ensure proper reporting ofabnormal events, effective air sampling of areas following a chemical release, andmedical treatment and evaluation guidelines following personnel exposures tohazardous chemicals.

The licensee performed an ACA for CR-4815 to determine why the internal and externalreporting of the HF vapor leak event was not completed in a timely manner. The ACAnoted a number of inappropriate actions by the licensee’s staff in the reporting of the HFvapor leak event. The root cause of the failure by the operations supervision to notifyEHS&L of the HF leak, and the failure of first line EHS&L supervision to perform areportability evaluation of the HF leak, was due to less than adequate communicationsand a failure to adhere to procedural requirements for reporting of abnormal or unusualevents. As a corrective action, the licensee committed to revise operations and EHS&Lprocedures and associated training to ensure proper evaluation and timely reportingupon discovery of unusual events. The inspectors determined that the ACA preventiveactions taken to address the internal and external communication issues and for thereporting of the event was appropriate. The root cause of the failure to report the eventin a timely manner to the NRC in accordance with 10 CFR 70 Appendix A (b)(1) was theresult of the EHS&L manager incorrectly assuming the HF leak event was covered bythe existing ISA for the dry conversion process and did not represent an unanalyzedaccident scenario. The inspectors verified the licensee had taken corrective actions toidentify other potential HF-only leak scenarios in their facilities and updated the ISAdocumentation.

b. Conclusions

The inspectors concluded that the licensee’s analysis and identification of contributingcauses and inappropriate actions which led to the failure of the conversion reactor andsubsequent leak of HF was satisfactory. The inspectors concluded that the licensee hasadequately identified causal factors in ACA CR-4815 and taken corrective actions toensure a more effective organizational response to unusual events. The inspectors alsodetermined that the licensee’s identification of causal factors/inappropriate actions intheir ACA CR-4816 along with the corrective and preventive actions taken to preventrecurrence were satisfactory to ensure timely reporting

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7. Licensee’s Assessment of Exposed Workers

a. Inspection Scope and Objectives

The inspectors interviewed the HST, CT, HST Supervisor, and EHS&L staff regardingthe response to the exposed workers to determine if an adequate and timelyassessment was performed. Based on interviews with cognizant personnel and areview of the NRC established event time-line, the assessment of the HST and CTphysical condition by the staff was timely. Immediately after the CT completed airsampling for HF and exited the process area, the CT was met by the HST Supervisorand questioned regarding his condition. The CT indicated that he was okay but noticeda slight burning sensation in his nose and throat. Approximately two hours later during aplant walkthrough, the CT discussed with the HST supervisor that the slight burningsensation in his nose and throat continued. Based on interviews with both the CT andHST supervisor, the explanation provided regarding HF effects (consequences,complications and delayed effects) were not emphasized and thoroughly communicated,and resulted in the technician’s hospitalization several hours after leaving work. Thephysical review of the CT condition, although timely, was insufficient.

b. Conclusions

The physical review of the CT condition, although timely, was insufficient as evidencedby his subsequent hospitalization for treatment of symptoms related to HF exposure.

8. Training Program and Procedures for Responding to Hydrogen Fluoride Events

a. Inspection Scope and Observations

The inspectors reviewed the licensee's training program and emergency procedures forresponding to HF events, and interviewed training personnel and chemical areaoperators to evaluate the adequacy of the program. The inspectors noted that thetraining curriculum for chemical operators did not address HF hazards and processlocations where these hazards may be present within the DCF. The interviewees statedthat the operator training was based on the operating procedures that the operatorsused as part of the regular job activities. The inspectors reviewed many of the DCFoperating procedures and noted that most of the DCF operating procedures which didnot involve handling of HF/UF6, did not address potential hazards that an operator mayexperience as part of the job activities. The inspectors determined that the generaltraining did not include a description of the hazards in each process area and thereforeDCF operators who do not work in the powder production process area would notreceive any training related to the potential hazards of HF exposure. Previously, thelicensee had offered a comprehensive training class related to HF hazards only uponrequest and was not part of the formal or mandatory training requirements for operators. Training records for previous HF hazards training were reviewed for personnel involvedin the HF release and determined that the CT had taken the class and the HST receivetraining as a member of the emergency response team known as “PERT.”

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The inspectors reviewed the existing emergency response procedures for HF release. The procedures did not address how to respond to small HF leaks within the conversionprocess. The procedures were focused on major UF6 and HF releases in thevaporization room, HF room, and the tank farm.

b. Conclusions

The inspectors determined that the licensee's HF training program and procedures forresponding to minor, off-normal, and unusual events involving UF6 and HF releases tobe insufficient for personnel who are not members of the emergency response team orwho do not work in the powder production process area.

9. Reactor Vessel Maintenance

a. Inspection Scope and Observations

The inspectors reviewed the available design data for the UF6 conversion reactor,including relevant safety documents, design and fabrication drawings, weld maps, andpurchase specifications. Documents examined by the inspectors included but were notlimited to:

! EMF-93-174(P), Revision 1, Dry Conversion Facility Hazards Evaluation

! E10-04-2.10, Integrated Safety Analysis, UO2 Building Drawing CSA-612,307,Revision 1, Sheet 2

! Conversion System Composite Vessel & Supports- Heating/Insulation JacketDrawing CSA-612,307, Revision 1, Sheet 3

! Conversion System Reactor Composite Filter Bonnet Weldment & AssemblyDrawing CSA-612,307, Revision 1, Sheet 5

! Conversion System Reactor Composite Body Weldment Drawing CSA-612,307,Revision 1, Sheets 6,7,8,9

! Conversion System Reactor Heating & Insulation Details DC-EQ-SP-005,Revision 2, Dry Conversion Equipment Specification: DC Reactor Vessels

The inspectors interviewed knowledgeable licensee staff regarding the operating historyof the equipment, as well as members of the licensee’s corrective action “metallurgy”team. The inspectors visually examined the affected Line 3 vessel head, as well as theunaffected equipment from Lines 1 and 2.

The inspectors determined that the conversion reactor was constructed of an inconelbody, with a monel filter bonnet. The equipment was designed and constructed toASME Code, Section VIII, Division 1 (Unfired Pressure Vessels). All welds were initiallysubjected to nondestructive examination via dye penetrant testing of both root passesand final welds. The unit was leak tested to 30 PSIG on initial installation.

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Documentation indicated that approximately two percent of the welds were subjected toradiographic examination. Post event testing of the cracked weld was performed by thelicensee and confirmed that it was applied using the correct filler material. Initial visualexamination of other welds indicated no gross imperfections. Later, the licenseediscovered a second crack at another location on the same filter bonnet. The inspectorsfound no documented details for the seal weld at the plug in question.

The inspectors verified that the vessel was subjected to a periodic visual examination ofits internals in accordance with Surveillance Procedure C820P001, as well as anultrasonic thickness measurement of the shell in accordance with C820P002, to ensurethat no erosion or corrosion was taking place which could affect the geometry of thevessel. It was noted that nondestructive examination of bonnet welds was not includedin the surveillances. Licensee staff stated that the internal sintered metal filters arereplaced periodically, and a visual examination takes place at that time. The inspectorsperformed a visual examination of the affected filter bonnet and filters in the “hot shop,”as well as an in-place visual examination of the other filter bonnets, and no evidence ofcorrosion or erosion was observed.

b. Conclusions

The inspectors confirmed that the conversion reactor and bonnet were properlydesigned. However, no additional examination of post-construction welds wasperformed. Installation of the plug at the failed seal weld was imperfect, anddocumentation of the seal weld was not available. These were contributing causes tothis event.

10. Exit Interviews

The inspection scope and results were summarized with licensee management in ameeting open to the public on November 2, 2006, and during a telephone exit onJanuary 19, 2007, with those persons indicated in the attachment. Although proprietaryinformation and processes were reviewed during this inspection, proprietary informationwas not included in this report. The Manager, EHS&L expressed disagreementregarding the basis for the reportability of the event.

ATTACHMENT

1. PARTIAL LIST OF PERSONS CONTACTED

Licensee *V. Gallacher, Manager, Uranium Conversion and Recovery#*R. Land, Vice President, Manufacturing#*R. Link, Manager, Environmental Health, Safety and Licensing *T. Longmire, Manager, Training *L. Maas, Manager, Licensing and Compliance#*C. Manning, Manager, Nuclear Criticality Safety *J. Payne, Manager, Technical Support and Maintenance#*C. Perkins, Site Manager #T. Tate, Manager, Safety, Security, and Emergency Preparedness *D. Durham, Supervisor, Health and Safety #*L. Tupper, Manager, Quality Assurance

Other licensee employees contacted included engineers, operators, supervisors,technicians, and maintenance craft personnel.

Nuclear Regulatory Commission*V. McCree, Deputy Regional Administrator for Operations, RII#D. Collins, Director, Division of Fuel Facility Inspection*D. Ayres, Chief, Fuel Facility Inspection Branch 1, RII#P. Habighorst, Chief, Fuel Manufacturing Section, NMSS

*Attended exit meeting on November 02, 2006#Participated in telephone exit on January 19, 2007

2. INSPECTION PROCEDURES (IPs) USED

IP 88003 Reactive Inspection For Events At Fuel Cycle FacilitiesIP 93812 Special Inspection

3. LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED

Item Number Status Description70-1257/2006-010-01 Open APV - Failure To Obtain Respiratory

Protection Equipment In Accordance WithMCPs 30102 and 30036 (Paragraph 2.a).

70-1257/2006-010-02 Open APV - Failure To Notify Onsite Personnel InAccordance With SOPs 40486, 40228, andEHS&L Procedure E18-01-002(Paragraph 2.a).

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70-1257/2006-010-03 Open APV - Failure To Meet The PerformanceRequirements Of 10 CFR 70.61(c)(4)(i)(Paragraph 2.a).

70-1257/2006-010-04 Open APV - Failure To Notify NRC In AccordanceWith 10 CFR 70 Appendix A(b)(1)(Paragraph 2.a).

4. LIST OF ACRONYMS USED

ACA Apparent Cause AnalysisAPV Apparent ViolationCT Conversion TechnicianDCF Dry Conversion FacilityEHS&L Environmental Health, Safety and LicensingHF Hydrogen FluorideHST Health and Safety TechnicianIROFS Items Relied On For safetyISA Integrated safety AnalysisMCP Management Control ProcedureNIOSH National Institute for Occupational Safety and HealthPPE Personal Protective EquipmentPPM Parts Per MillionRCA Root Cause AnalysisSIT Special Inspection TeamSOP Standard Operating ProcedureUF6 Uranium Hexafluoride