GO2-24-005, Docket No. 50-397 Supplement to Reply to a Notice of Violation; EA-21-170
| ML24008A181 | |
| Person / Time | |
|---|---|
| Site: | Columbia  |
| Issue date: | 01/08/2024 |
| From: | David Brown Energy Northwest |
| To: | Office of Nuclear Reactor Regulation, NRC Region 4, Document Control Desk |
| References | |
| GO2-24-005, EA-21-170 | |
| Download: ML24008A181 (1) | |
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David P. Brown ENERGY Site Vice President P.O. Box 968, PE23 NORTHWEST Richland, WA 99352-0968 Ph. 509-377-8385 F. 509-377-4150 dpbrown@energy-northwest.com
January 8, 2024 GO2-24-005 10 CFR 2.201
U.S. Nuclear Regulatory Commission ATTN: Document Control Desk Washington, DC 20555-0001
Subject:
COLUMBIA GENERATING STATION, DOCKET NO. 50-397 SUPPLEMENT TO REPLY TO A NOTICE OF VIOLATION; EA-21-170
References:
(1) Letter from D. Brown (Energy Northwest) to US Nuclear Regulatory Commission, "Reply to a Notice of Violation; EA-21-170,"
ML23193B032, GO2-23-090, dated July 12, 2023.
(2) Letter from D. Brown (Energy Northwest) to US Nuclear Regulatory Commission, "Supplement to Reply to a Notice of Violation; EA 170," ML23208A331, GO2-23-093, dated July 27, 2023.
(3) Letter EA-21-170 from R. Lewis (NRC) to R. Schuetz (Energy Northwest), Columbia Generating Station - Final Significance Determination of a White Finding, Notice of Violation and Follow-Up Assessment Letter; NRC Inspection Report 05000397/2023090, ML23111A237, dated June 1, 2023.
(4) Letter EA-23-054 from J. Monninger (NRC) to R Schuetz (Energy Northwest), Columbia Generating Station - Final Significance Determination of a White Finding, Notice of Violation and Follow-Up Assessment Letter; NRC Inspection Report 05000397/2023093, ML23276B477, dated November 1, 2023.
Dear Sir or Madam:
In accordance with 10 CFR 2.201 Energy Northwest submitted "Reply to a Notice of Violation; EA-21-170," (Reference 1) on July 12, 2023, and Supplement to Reply to a Notice of Violation; EA-21-170 (Reference 2), for Columbia Generations station on July 27, 2023. A consolidated root cause was performed looking at violations described in EA-21-170 (Reference 3) and EA-23-054 (Reference 4), as well as previously
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GO2-24-005 Page 2 of 2
performed root causes. As part of this review additional causes and corrective actions were identified and are being submitted to the NRC in this revision to the previous responses from Energy Northwest to the NRC in reference to EA-21-170.
The purpose of this letter is to notify the Nuclear Regulatory Commission of the new causal analysis conclusions by providing a revision to responses provided in Reference 1 and Reference 2. Updates and revisions to violation responses are annotated by change bars in the right-hand margin of the enclosure.
There are no commitments being made to the NRC by this letter. Should you have any questions, please contact IR Bitner, Regulatory Compliance Supervisor, at (509) 377-4204.
Executed this ____ day of ____________, 2024. " # !%
Respectfully,
David P. Brown Site Vice President
Enclosure:
Revision to Reply and Supplement to Reply to EA-21-170 Notice of Violation
cc: NRC Director-Division of Operating Reactor Safety, Region IV NRC Region IV Administrator NRC NRR Project Manager NRC Resident Inspector/988C NRC Enforcement, Region IV CD Sonoda - BPA/1399 w/o enclosure
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GO2-24-005 Enclosure
Columbia Generating Station - Energy Northwest Revision to Reply and Supplement to Reply to EA-21-170 Noti ce of Violation
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GO2-24-005 Enclosure Page 2 of 10
As noted in Energy Northwests July 12, 2023, letter to the U.S. Nuclear Regulatory Commission (NRC) (Reference 1) and July 27, 2023, letter to the U.S. Nuclear Regulatory Commission (Reference 2), Energy Northwest accepts the violations documented in NRC Inspection Report 0500 0397/2023090, has taken prompt action to return to full compliance and has implemented comprehensive corrective actions for long-term sustained compliance related to the violations of 10 CFR 20.1701, Technical Specification 5.7.2.b, and 10 CFR 20.1501(a)(2).
A consolidated root cause evaluation has been completed which reviewed both the violations noted in the June 1, 2023, final determination letter (Reference 3) and the violation noted in the November 1, 2023, final determination letter (Reference 4) as well as previous root causes performed. Below is a revised reply to EA-21-170 notice of violation including results from the newly performed root cause. Updates and revisions to violation responses are annotated by change bars in the right-hand margin.
NRC letter dated June 1, 2023, (Reference 3) cited three violations of NRC requirements.
A. Violation of 10 CFR 20.1701
Notice of Violation
10 CFR 20.1701 requires, in part, that the licensee shall use, to the extent practical, process or other engineering controls to control the concentration of radioactive material in air.
Contrary to the above, on May 28, 2021, the licensee failed to use, to the extent practical, process or other engineering controls to control the concentration of radiation material in air. Specifically, the licensee did not properly plan for the use of engineering controls with enough specificity in accordance with station procedures (i.e., procedure HPI-12.90, Contamination Control Containment Devices) to ensure proper control for installation and removal of the glove bag, which is used to prevent airborne contamination. The failure to ensure proper control of the glove bag resulted in an airborne contamination event that caused two individuals to receive internal doses of greater than 700 millirem committed effective dose equivalent.
Reason for Violation
The root cause of the violation was determined to be that radiological risk for the work was evaluated by staff presupposing the successful use of engineering controls to mitigate radiological hazards and didnt evaluate or recognize the overall risk associated with the work being performed or potential consequences of engineering control failure or incorrect use. The direct cause was improper setup, use (without High-Efficiency Particulate Air [HEPA] vacuum), and removal of a glove bag (engineering control) while performing pipe preparation activities.
Contributing causes included the station procedure for glove bag use was not
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used and individuals working nightshift did not perform an effective mockup using the glove bag.
Radiation Protection (RP) leaders were ineffective in shaping organizational behaviors and reinforcement of programmatic standards leading to inadequate demonstration of radiological command and controls.
Job planning activities were not rigorous to promote consistent job performance.
The as low as reasonably achievable (A LARA) plan was not specific or detailed enough to ensure the requirements were translated into the Radiation Work Permit (RWP) and Work Package implementing documents. Additionally, the ALARA Plan assumed a high level of skill and proficiency of the craft performing this work, which was not the case.
RP technicians, leads and supervisors did not uphold fundamental radiation safety standards related to positive RP command and control and adherence to relevant procedures.
Corrective Steps and Results Achieved
Immediate actions taken include:
x A formal stop work order was issued for the evolution, and the entire project team conducted a stand down to discuss the event (including immediate lessons learned).
x A prompt Human Performance event investigation was performed, and individuals involved in the event were interviewed.
x The RWP was revised to require respirators to be worn during pipe preparations for the remaining two pipe weld preparations.
x The dayshift RP technicians were tasked to prepare, install, and remove the glove bags since they were more proficient with glove bag use.
x Prior to the restart of pipe preparations an implementation plan was developed to ensure the preparation of the remaining cut locations were prepared with proper, approved engineering controls in place and that the room be free from unrelated personnel during the work.
Additional actions taken include:
x The station Health Physics Instruction HPI-12.90, Contamination Control Containment Devices was updated to add a requirement for just-in-time-training via mockup, a formal written plan, and a verification that the correct breather filter is installed when using a glove bag as a containment device.
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x The station Plant Procedure Manual 11.2.8.2, Radiation Work Permit Preparation and Use was revised to include a hold point when glove bags are used to control the spread of radioactivity to the air as well as require size and type of glove bag to be specified as part of the RWP.
x The station Plant Procedure Manual 11.2.2.12, Radiological Risk Assessment and Management was updated to determine initial risk assuming no elimination or mitigation actions, define risk mitigation and risk elimination actions, and only allow the risk categorization to credit an action that eliminates the risk.
x Gap training was performed for qualified individuals and RP supervisors on the revised Radiological Risk Assessment and Management procedure.
x Form 26840, Radiological Risk Assessment Checklist was revised to make abrasive work on highly contaminated surfaces (i.e., >100 mrad/hr/100 cm2) high radiological risk.
x The station Health Physics Instruction HPI-0.41, Expectations for Radiological Job Coverage was revised to include RP responsibilities for installation and removal of containment devices.
x Gap training for ALARA Planners was given to include key references (i.e., procedure numbers, forms, etc.) in the ALARA plan.
x An effectiveness review was completed on August 29, 2023.
x The station Radiological Risk Assessment and Management procedure as well as other related procedures were revised with the results of:
o Benchmarking other stations ALARA planning processes, including ALARA planning risk identification and mitigation.
x Actions have been taken to ensure RP management assigns a direct report to oversee high and elevated risk ALARA plans with responsibility to ensure the plan has adequate detail to be incorporated into, or has been incorporated into, RWPs and the Work Packages to drive consistent performance and minimize the risk of an event of consequence. The level of oversight is to be commensurate with risk significance.
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Corrective Steps that Will be Taken
x Conduct an evaluated Dynamic Learning Activity (DLA) for Energy Northwest and Contract RP Technicians, RP Supervisors, Planners and Support Staff to include:
o Fundamental Radiation Safety Standards
o Positive RP command and control of radiological work activities
o Prudent over simply allowable approach to decisions related to control of radiological jobs.
x Establish initial and periodic evaluated DLAs and Oral Boards for EN and Contract RP Technicians, RP Supervisors, Planners and Support Staff on:
o Fundamental Radiation Safety Standards
o Positive RP command and control of radiological work activities o Prudent over simply allowable approach to decisions related to control of radiological jobs.
Date of Full Compliance
Full compliance with 10 CFR 20.1701 was achieved upon completion of all actions, with the exception of the Effectiveness Review, under Condition Report 00420829 on December 28, 2022.
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B. Violation of Technical Specification 5.7.2.b
Notice of Violation
Technical Specification 5.7.2.b requires, in part, that access to, and activities in, each high radiation area with dose rates greater than 1.0 rem/hour at 30 centimeters from the radiation source shall be controlled by means of a radiation work permit.
Radiation work permit 30004732, created to control activities in a Technical Specification 5.7.2.b high radiation area, required, in part, that continuous Health Physics job coverage is provided when personnel are entering and working in areas with dose rates greater than 0.8 rem/hour.
Contrary to the above, on May 28, 2021, the licensee failed to control the activities in a high radiation area with dose rates greater than 1.0 rem/hour at 30 centimeters from the radiation source in accordance with radiation work permit 30004732. Specifically, the licensee failed to follow radiation work permit 30004732 and provide continuous Health Physics job coverage when personnel entered and worked in an area with dose rates greater than 0.8 rem/hour (i.e.,
1.3 rem/hour at 30 centimeters from the radiation source). A radiation protection technician, scheduled to provide the continuous Health Physics job coverage, was unable to physically fit on the work area platform and left the workers unattended in the area. A second radiation protection technician subsequently replaced the original technician as the workers were conducting job activities in the work area.
Reason for Violation
The direct cause identified was inadequate adherence and implementation of station and department-level instructions, policies, and procedures which resulted in approval and implementation of plans that were not appropriate to support successful performances of infrequently performed activities, were insufficient to mitigate risk, or included error traps.
Additionally, disposition of adverse events by the Radiological Services group (by application of the station corrective action program) was not performed in a manner which facilitated identification and resolution of systemic level shortcomings in station radiological controls.
Radiological Services resources were challenged to ensure correct implementation of planned work in all cases.
RP leaders were ineffective in shaping organizational behaviors and reinforcement of programmatic standards leading to inadequate demonstration of radiological command and controls.
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RP technicians, leads and supervisors did not uphold fundamental radiation safety standards related to positive RP command and control and adherence to relevant procedures.
The RP technicians and RP Supervision did not provide positive RP command and control of radiological work activities.
Radiation Services personnel did not demonstrate a prudent approach when making several decisions related to control of the job, which was an infrequently performed evolution and posed unplanned radiological risk.
Corrective Steps and Results Achieved
x Developed and implemented a required formal as low as reasonably achievable (ALARA) plan review tool for elevated and high radiological risk activities.
x Revised Corrective Action program procedures, instructions, and related guidance to preclude use of human error or culpability for root, apparent, and contributing causes and analytical products.
x Developed a job familiarization guide (JFG) with specific focus on management of Radiological Services outage resources.
Corrective Steps that Will be Taken
Actions to be taken include:
x Conduct an evaluated Dynamic Learning Activity (DLA) for Energy Northwest and Contract RP Technicians, RP Supervisors, Planners and Support Staff to include:
o Fundamental Radiation Safety Standards
o Positive RP command and control of radiological work activities
o Prudent over simply allowable approach to decisions related to control of radiological jobs.
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x Establish initial and periodic evaluated DLAs and Oral Boards for EN and Contract RP Technicians, RP Supervisors, Planners and Support Staff on:
o Fundamental Radiation Safety Standards o Positive RP command and control of radiological work activities
o Prudent over simply allowable approach to decisions related to control of radiological jobs.
Date of Full Compliance
Full compliance was achieved on May 29, 2021, upon approval of return-to-work criteria.
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C. Violation of 10 CFR 20.1501(a)(2)
Notice of Violation
10 CFR 20.1501(a)(2) requires, in part, that licensees shall make surveys of areas that are reasonable under the circumstances to evaluate the magnitude and extent of radiation levels; and concentrations or quantities of residual radioactivity.
Contrary to the above, on May 27, 2021, the licensee failed to make surveys of areas that were reasonable under the circumstances to evaluate the magnitude and extent of radiation levels; and concentrations or quantities of residual radioactivity. Specifically, the licensee failed to adequately determine the work area radiation levels as documented in survey M-20210528-13, which stated, the survey was not an extensive search for the highest exposure rate. In addition, the licensee failed to adequately evaluate the extent of contamination levels on the piping prior to the work activity. The surveys completed prior to the event did not adequately identify work area dose rates and did not identify appropriate contamination levels, resulting in a lower risk rating to the job and less rigorous radiological controls for the activity.
Reason for Violation
The cause identified was ineffective enforcement of station/department standards, policies, and administrative controls, due to inadequate review and approval processes.
Additionally, disposition of adverse events by the Radiological Services group (by application of the station corrective action program) was not performed in a manner which facilitated identification and resolution of systemic level shortcomings in station radiological controls.
Radiological Services resources were challenged to ensure correct implementation of planned work in all cases.
RP leaders were ineffective in shaping organizational behaviors and reinforcement of programmatic standards leading to inadequate demonstration of radiological command and controls.
RP technicians, leads and supervisors did not uphold fundamental radiation safety standards related to positive RP command and control and adherence to relevant procedures.
The RP technicians and RP Supervision did not provide positive RP command and control of radiological work activities.
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Corrective Steps and Results Achieved
x Developed and implemented a formal survey review tool required to be completed for approving surveys. Completed reviews should be attached to surveys for periodic quality reviews.
x Revised Corrective Action program procedures, instructions, and related guidance to preclude use of human error or culpability for root, apparent, and contributing causes and analytical products.
x Developed a job familiarization guide (JFG) with specific focus on management of Radiological Services outage resources.
Corrective Steps that Will be Taken
Actions to be taken include:
x Conduct an evaluated Dynamic Learning Activity (DLA) for Energy Northwest and Contract RP Technicians, RP Supervisors, Planners and Support Staff to include:
o Fundamental Radiation Safety Standards o Positive RP command and control of radiological work activities
o Prudent over simply allowable approach to decisions related to control of radiological jobs.
x Establish initial and periodic evaluated DLAs and Oral Boards for EN and Contract RP Technicians, RP Supervisors, Planners and Support Staff on:
o Fundamental Radiation Safety Standards
o Positive RP command and control of radiological work activities
o Prudent over simply allowable approach to decisions related to control of radiological jobs.
Date of Full Compliance
Full compliance was achieved on May 29, 2021, upon approval of return-to-work criteria.