05000528/FIN-2011005-01
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Finding | |
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| Title | Failure to Evaluate a Radiological Hazard |
| Description | The inspectors reviewed a self-revealing, non-cited violation of 10 CFR 20.1501(a), resulting from the licensees failure to evaluate the hazard associated with breaching a contaminated system. On October 18, 2011, before and during work on Unit 1 in the letdown heat exchanger valve CHNV340, the licensee did not make or cause to be made surveys necessary for the licensee to comply with 10 CFR 20.1201(a), the occupational dose limits to adults. The violation resulted in four workers receiving unplanned internal dose. The licensee took corrective action to secure similar valve work pending review of the personnel contamination events; required the use of respiratory protection for subsequent work on the same valve; revised the governing radiation exposure permit; briefed outage personnel on the occurrence; and performed an apparent cause evaluation as part of Condition Report Disposition Request 3919188. The failure to evaluate the radiological hazard was a performance deficiency. The performance deficiency was more than minor, and therefore a finding, because it is associated with the Occupational Radiation Safety Cornerstone attribute of program and process and adversely affected the cornerstone objective of ensuring adequate protection of worker health and safety from exposure to radiation. Specifically, the failure to evaluate the radiological hazard resulted in unplanned and unintended dose to personnel. Using Inspection Manual Chapter 0609, Appendix C, Occupational Radiation Safety Significance Determination Process, the inspectors determined the finding to be of very low safety significance because: (1) it was not an as low as is reasonably achievable 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 inspectors determined this finding had a cross-cutting aspect in the area of human performance associated with the work control component. Specifically, the licensee did not appropriately plan a work activity by incorporating risk insights because the station lacked a systematic and rigorous process for risk assessment on alpha contamination |
| Site: | Palo Verde  |
|---|---|
| Report | IR 05000528/2011005 Section 2RS1 |
| Date counted | Dec 31, 2011 (2011Q4) |
| Type: | NCV: Green |
| cornerstone | Or Safety |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71124.01 |
| Inspectors (proximate) | L Ricketson G Guerra R Lantz M Brown B Baca D Allen J Melfi B Parks A Fairbanks E Uribe M Baquera D Reinert S Hedger |
| CCA | H.5, Work Management |
| INPO aspect | WP.1 |
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Finding - Palo Verde - IR 05000528/2011005 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Palo Verde) @ 2011Q4
Self-Identified List (Palo Verde)
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