05000410/FIN-2016002-03
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Finding | |
|---|---|
| Title | Failure to Understand Radiological Conditions Results in Unintended Exposure |
| Description | A self-revealing NCV of TS 5.4.1 Procedures was identified when a worker performed a radiological work activity without notifying radiation protection personnel and, as a result, did not comply with procedure RP-AA-1008, Unescorted Access to and Conduct in Radiologically Controlled Areas, Revision 5, in being briefed on the necessary radiological work controls and conditions for performance of the Unit 2 reactor seal cleaning work activity. Specifically, on April 11, 2016, a worker entered the Unit 2 reactor cavity to perform inspection of the reactor seal that was highly contaminated. Although not previously discussed with radiation protection staff, the worker cleaned the highly contaminated reactor seal with rags and carried the highly contaminated rags (5 rem/hr) in his hand out of the reactor cavity, which resulted in unplanned radiation exposure to the workers hand. Exelons immediate corrective actions included reinforcing the need to properly communicate radiological work activities with radiation protection, and require workers to carry WOs with them to improve communications with radiation protection. Exelon entered the issue into the corrective action program (CAP) as IR 02654591. The failure of the worker to discuss the full scope of the radiological work activity with radiation protection staff, who were subsequently not effectively briefed on the expected radiological work conditions and requisite radiological controls needed for the work activity, is a performance deficiency that was reasonably within Exelons ability to foresee and correct. The finding was determined to be more than minor because it affected the human performance attribute of the Occupational Radiation Safety cornerstone objective. Using IMC 0609, Appendix C, Occupational Radiation Safety Significance Determination Process, the finding was determined to be of very low safety significance (Green) because it did not involve: (1) as low as reasonably achievable (ALARA) occupational collective exposure planning and controls, (2) an overexposure, (3) a substantial potential for overexposure, or (4) an impaired ability to assess dose. The finding is self-revealing because Exelon was made aware of the situation when an air monitor alarmed. The finding had a cross-cutting aspect of Human Performance, Team Work, since individuals and work groups did not communicate and coordinate their activities within and across organizational boundaries to ensure nuclear safety was maintained. Specifically, the worker did not adequately communicate to radiation protection staff, the reactor seal cleaning activity to be performed. As a result, radiation protection personnel did not prescribe sufficient radiological controls for this high-contamination work activity, and led to an unintended exposure to the workers hand. |
| Site: | Nine Mile Point  |
|---|---|
| Report | IR 05000410/2016002 Section 2RS1 |
| Date counted | Jun 30, 2016 (2016Q2) |
| Type: | NCV: Green |
| cornerstone | Or Safety |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71124.01 |
| Inspectors (proximate) | A Rosebrook C Graves C Roettgen E Miller G Stock K Kolaczyk M Scott N Floyd S Galbreath |
| Violation of: | Technical Specification - Procedures |
| CCA | H.4, Teamwork |
| INPO aspect | PA.3 |
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Finding - Nine Mile Point - IR 05000410/2016002 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Nine Mile Point) @ 2016Q2
Self-Identified List (Nine Mile Point)
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