05000334/FIN-2017004-01
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Finding | |
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| Title | Inadequate Control of Entry into High Radiation Areas |
| Description | A self-revealing, very low safety significance NCV of Technical Specification (TS) 5.7.1 for failure to control a high radiation area (HRA) was identified. On November 8, 2017, during independent spent fuel storage installation (ISFSI) dry cask loading campaign activities, the failure of multiple barriers resulted in a worker gaining access to an HRA while signed onto an incorrect radiation work permit (RWP) and a subsequent dose rate alarm. Specifically, a worker signed on to an incorrect RWP during a break, and did not recognize that the surveyed work area dose rates were higher than the RWP setpoints. Additionally, radiation protection personnel controlling access to the HRA failed to ensure that the worker was on the correct RWP per plant procedure requirements for a subsequent entry into anHRA. This resulted in the worker entering an HRA under the incorrect RWP and receiving a dose rate alarm of 1,070 millirem per hour. Upon receiving a dose rate alarm, the worker backed away from the area and reported the issue to radiation protection personnel. FENOCs immediate corrective actions included putting the work in a safe condition, performing follow-up surveys, and verifying remaining personnel trip tickets to ensure all individuals were on the correct RWP. FENOC entered the issue into their corrective action program (CAP) as condition report (CR) 2017-11206.The failure to control access to an HRA is a performance deficiency that was within FENOCs ability to foresee and correct and should have been prevented. The performance deficiency is more than minor because it is associated with the Program and Process attribute (Procedures) of the Occupational Radiation Safety cornerstone and adversely affected the cornerstone objective of ensuring adequate protection of worker health and safety from exposure to radiation from radioactive material during routine reactor operation. Specifically, the failure of multiple barriers resulted in a worker gaining access to an HRA while signed on to an incorrect RWP and receiving a dose rate alarm. IMC 0612, Appendix E, Section 6, Health Physics, General Screening Criteria, states that a performance deficiency involving more than one barrier or the loss of a significant barrier would be classified as a more-than-minor performance deficiency. Using IMC 0609,Appendix C, Occupational Radiation Safety Significance Determination Process, the finding was determined to be of very low significance (Green) because: (1) it was not an as low as reasonably achievable (ALARA) finding, (2) there was no overexposure, (3) there was no substantial potential for an overexposure, and (4) the ability to assess dose was not compromised. The finding was a human performance cross-cutting aspect associated with avoiding complacency because FENOC failed to ensure individuals recognize and plan for the possibility of mistakes and ensure individuals implement the appropriate error reduction tools, even when expecting a successful outcome [H.12] |
| Site: | Beaver Valley |
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| Report | IR 05000334/2017004 Section 4OA5 |
| Date counted | Dec 31, 2017 (2017Q4) |
| Type: | NCV: Green |
| cornerstone | Or Safety |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 60855.1 |
| Inspectors (proximate) | J Krafty S Haney S Horvitz J Deboer M Modes J Nicholson R Rolph K Warner S Kennedy |
| Violation of: | Technical Specification |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Beaver Valley - IR 05000334/2017004 | |||||||||||||||||||||||||||||||||||
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Finding List (Beaver Valley) @ 2017Q4
Self-Identified List (Beaver Valley)
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