05000528/FIN-2016002-03
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Finding | |
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| Title | Inadequate Engineering and Radiological Controls Resulting in a Unit 1 Containment Building Airborne Radioactivity Event with Unplanned Intakes |
| Description | The inspectors identified a non-cited violation of 10 CFR 20.1701 due to the licensees failure to implement adequate processes and engineering controls necessary to reduce airborne radioactivity and prevent internal dose to workers in Unit 1. On April 20, 2016, inspectors identified that procedures and instructions for monitoring high efficiency particulate air ventilation filter unit to prevent worker exposures to radiation and airborne radioactivity were being inadequately implemented. On April 21, 2016, the licensees inadequate engineering and radiological controls during a high efficiency particulate air operations caused an airborne radioactivity event in containment, resulting in the evacuation of 41 potentially contaminated workers of whom 8 had measurable intakes of radioactive material. The licensees immediate corrective actions included stopping work in the Unit 1 containment, evacuating workers in containment, assessing workers for external and internal contamination, and investigating the cause and source of the contamination event. This matter was placed in the licensees corrective action program as Condition Reports16-06499 and 16-06578 and the licensee initiated a root cause investigation. The inspectors determined that the failures to implement adequate engineering and radiological controls to reduce airborne radioactivity during a high efficiency particulate air unit operations in accordance with 10 CFR 20.1701 and radiation protection procedures were performance deficiencies. The performance deficiencies were more than minor because they were associated with the Occupational Radiation Safety Cornerstone attribute of program and process (exposure control) and adversely affected the cornerstone objective to ensure the adequate protection of the worker health and safety from exposure to radiation from radioactive material during routine civilian nuclear reactor operation. This was evident by the Unit 1 containment airborne radioactivity event on April 21, 2016, that resulted in at least eight workers with unplanned intakes. Using Inspection Manual Chapter 0609, Appendix C, Occupational Radiation Safety Significance Determination Process, dated August 19, 2008, the inspectors determined the finding had very low safety significance (Green) because: (1) it was not an as low as is reasonably achievable planning and controls 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 concluded that the finding has a cross-cutting aspect in the human performance area, associated with the resources component, because the licensee leaders failed to ensure that personnel, equipment, procedures, and other resources were available and adequate to support nuclear safety. Specifically, procedures and radiation exposure permits failed to have adequate instructions for ensuring a high efficiency particulate air filter loading and dose rates were monitored to prevent overloading, and safe handling of loaded a high efficiency particulate air filters [H.1]. |
| Site: | Palo Verde  |
|---|---|
| Report | IR 05000528/2016002 Section 2RS3 |
| Date counted | Jun 30, 2016 (2016Q2) |
| Type: | NCV: Green |
| cornerstone | Or Safety |
| Identified by: | NRC identified |
| Inspection Procedure: | IP 71124.03 |
| Inspectors (proximate) | C Peabody D Reinert D You G Guerra G Miller G Pick I Anchondo J Drake L Carson N Greene D Tailleart |
| Violation of: | 10 CFR 20, Standards for Protection Against Radiation 10 CFR 20.1701, Respiratory Protection and Controls to Restrict Internal Exposure in Restricted Areas |
| CCA | H.1, Resources |
| INPO aspect | LA.1 |
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Finding - Palo Verde - IR 05000528/2016002 | ||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Palo Verde) @ 2016Q2
Self-Identified List (Palo Verde)
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