05000440/FIN-2011002-01
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Finding | |
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| Title | Failure to Establish Radiological Conditions in a Locked HRA [i.e., the fuel pool cooling and cleanup (FPCC) heat exchanger room] Prior to Allowing Personnel Access |
| Description | A finding of very low safety significance and an associated NCV of Technical Specifications (TS) 5.7.2 was self-revealed following the licensees failure to adequately identify the radiological conditions in the fuel pool cooling and cleanup (FPCC) heat exchanger room prior to a pre-job brief for work in the room and prior to workers entering the room. Specifically, on November 19, 2010, operators involved in tag-out activities for a valve encountered elevated dose rates when they entered an un-surveyed area on the back side of the FPCC heat exchanger. At the time the FPCC room was controlled as a locked high radiation area (HRA). While entering the area one of the operators received an electronic dosimeter (ED) dose rate alarm of 1500 mRem/hr. Follow-up surveys determined that the highest dose rate in the area entered was 2000 mrem/hr. As part of the licensees corrective actions, lessons learned were shared with the radiation protection (RP) staff to address survey and briefing inadequacies. Additional performance management actions were implemented by the station. The inspectors determined that the licensees failure to adequately identify the radiological conditions in the room prior to workers entering the work area was a performance deficiency. The inspectors determined that the finding was more than minor because the inspectors identified Example 6(h) of IMC 0612, Appendix E, as similar to the finding; the workers were not made aware of the radiological conditions before entry into the area on the back side of the FPCC heat exchanger. Additionally, the finding impacted the program and process attribute of the Occupational Radiation Safety Cornerstone by adversely affecting the cornerstone objective of ensuring adequate protection of worker health and safety from exposure to radiation in that workers entry into areas, without knowledge of the radiological conditions, placed them at increased risk for unnecessary radiation exposure. The finding was determined to be of very low safety significance because the performance deficiency was not an as-low-as-reasonably-achievable (ALARA) planning issue, there was no overexposure, nor substantial potential for an overexposure, and the licensees ability to assess dose was not compromised. The inspectors determined that the cause of this incident involved a cross-cutting component in the human performance area of work practices in that the work crew proceeded in the face of uncertainty when unexpected circumstances were encountered in the FPCC heat exchanger room. |
| Site: | Perry  |
|---|---|
| Report | IR 05000440/2011002 Section 2RS1 |
| Date counted | Mar 31, 2011 (2011Q1) |
| Type: | NCV: Green |
| cornerstone | Or Safety |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71124.01 |
| Inspectors (proximate) | R Leidy J Cameron T Hartman P Smagacz M Marshfield M Phalen |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Perry - IR 05000440/2011002 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Perry) @ 2011Q1
Self-Identified List (Perry)
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