IR 05000219/1986028

Insp Rept 50-219/86-28 on 860818-20 & 0908-11.Violation Noted:No Survey Made on Replaced Pump Seal,Per 10CFR20.202. Concerns Re Control of Work Noted

ML20213E637
Person / Time
Site:	Oyster Creek
Issue date:	11/06/1986
From:	Shanbaky M, Sherbini S NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:
Shared Package
ML20213E600	List: IR 05000219/1986028 ML20213E597 ML20213E611
References
50-219-86-28, NUDOCS 8611130238
Download: ML20213E637 (6)

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U.S. NUCLEAR REGULATORY COMMISSION

REGION I

Report N /86-28 Docket N License N DPR-16 Priority --

Category C Licensee: GPU Nuclear Corporation P.O. Box 388 Forked River, New Jersey 08731 Facility Name: Oyster Creek Nuclear Generating Station Inspection At: Forked River, New Jersey Inspection Conducted: August 18-20 and September 8-11, 1986 Inspectors: ON ' '

S. Sherbini, Radiation Specialist ll [kl96'i date Facilities Radiation Protection Section

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Approved by: ,M W / //

M.'M. Shanbaky', ~ Chief, Fp(111 ties Radiation

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!/'TI date Protection Section Inspection Summary: Inspection on August 18-20 and September 8-11, 1986 Areas Inspected: A reactive inspection to review the circumstances connected with an unplanned exposure during a mechanical seal replacement on a reactor coolant recirculation pum Results: Several concerns were identified regarding control of this wor One violation of 10 CFR Part 20 requirements was identifie Nk k Q

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DETAILS 1.0 P_ersonnel Contacted 1.1 Licensee Personnel G. Amatucci, Catalytic Site Manager

• K. Bass, MCF Manager of Construction

• P. Calandra, MCF Radiological Engineer W. Coyne, Catalytic Millwright M. Davis, Catalytic Job Supeevisor E. Golomb, Radiological Controls Technician R. Hef fner, Radiological Controls Supervisor

• M. Leavitt, Radiological Controls Deputy Director

• M. Littleton, Manager, Radiological Engineering J. Olansen, MCF Director (Acting)

E. Riggle, Training

• J. Rogers, Licensing Engineer D. Turner, Director, Radiological Controls 1.2 NRC Personnel

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_ * Bateman, Senior Resident Inspector .

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• J. Wechselberger, Resident Inspector

• Denotes attendance at the exit intervie .0 Purpose The purpose of this reactive inspection was to investigate the circum-stances surrounding an administrative overexposure. The overexposure involved one Catalytic millwright and occurred during maintenance work on the mechnical seal of recirculation pump "D". Areas reviewed included the following:

Job planning by Maintenance, Facilities, and Construction (MCF)

ALARA review

RWP generation

Mock-up training

Respiratory protection

Surveys during job execution

Post-job analysis

Corrective actions 3.0 Description of Circumstances The work involved a recirculation pump mechanical seal replacement and rebuilding. The pump in question is recirculation pump N1010. The seal replacement was performed in'accordance with procedure 703.1.004, Rev 10,

" Reactor Recirculation Pump Mechanical Seal Removal, Rebuild, and

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Installation". This procedure addresses only the mechanics of seal replacement and not the activities surrounding the overall job, such as scaffolding, radiological controls, et An ALARA review for the job was requested on March 11, 1986 and the review was completed within about two weeks. A completion date is not indicated on the review sheet. The ALARA review was revised on April 11, 1986. The review was not based on actual surveys because it was completed before chemical decontamination of the system. It was based on data from three similar jobs performed in 1983(1740-83,1833-83, 1950-83). The review estimated a maximum exposed individual dose of 300 mrem and a job total exposure of 6000 man-mrem. This implies a minimum of 20 people involved in the wor The ALARA review was assigned a review number 86-12 A series of mock-up training sessions was conducted at the Oyster Creek training facility between June 20, 1986 and July 2, 1986. Eight persons were trained, all Catalytic workers, and all but one received a total of 16 hours1.851852e-4 days <br />0.00444 hours <br />2.645503e-5 weeks <br />6.088e-6 months <br /> of mock-up training. The exception was the job foreman, who received eight hours of training. The training was conducted under the Mechanical Maintenance Program and the lesson title was " Recirculation Pump Mechanical Seal Maintenance".

A job-specific RWP was requested by the Catalytic job foreman on July 24, 1986 and the survey for the RWP was made on July 25, 1986. The RWP was approved and issued on July 25, 1986, with an expiration date of August 25, 1986. The RWP number was 1098-86 and it incorporated ALARA review 86-124 as an attachment. The survey used by the RWP was survey number 8166-8 . Work started on the pump seal on approximately July 30, 1986 and continued intermittently until the RWP was suspended by Radiological Controls on August 7, 1986 due to anomalous dosimetry result From the start of the job until August 6, 1986, the RWP required that whole body dosimetry be worn on the chest. This dosimetry included a TLD, a 0-200 mR SRD, and a 0-500 mR SRD. Extremity cosimetry was not required, but the required equipment included anti-contamination clothing, a full-face negative pressure respirator, and a lapel sample A survey instrument was also used by the workers during the entries into the drywell. The drywell at that time was posted a high contamination area and the work area was a high radiation are On August 6, 1986, one of the workers on the pump seal job placed a 0-500 mR SRD below his knee before entering the drywell. This was done on his own initiative, without knowledge of Radiological Controls. Upon exiting the drywell 90 minutes later, the control point clerk noted that the knee dosimeter registered 40 mR higher than the chest dosimeter. The chest

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dosimeter registered 85 mR as per the sign-in sheet. The 40 mR difference in SRD readings was brought to the attention of the Group i

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Radiological Controls Supervisor (GRCS) on shift at that time. The supervisor decided to change the whole body dosimetry placement from the chest to the thigh. A note to that effect was added to the job RWP on August 6, 198 On August 7, 1986, two workers entered on the seal replacement RWP. One

' of them apparently misunderstood the revised dosimetry placement requirements on the RWP and placed his TLD and 0-200 mR SRD on his chest and the 0-500 mR SRD on his thigh. The entry lasted 90 minutes, and upon exit, it was found that this worker's thigh SRD read approximately 7 times higher than his chest SRD. The chest SRD read 70 mR. The discrepancy was once again reported to the GRCS, who then decided to suspend the RWP pending investigation into the cause of the discrepanc Radiological Engineering carried out a series of calculations to adjust

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the assigned whole body doses of the workers involved in this job. This was necessary because the SRD readings indicated that the whole body dosimetry was not placed in the area of highest exposure to the worker's bodies. As part of the licensee's investigation, interviews were conducted with the workers, and two radiological surveys of the work area were mad The surveys were both made on August 8, 1986, and the survey numbers were 9166-86 and 9201-86. The calculations indicated that the following adjustments should be made to the whole body doses assigned to the workers:

Worker #1 from 58 mR to 232 mR for July from 70 mR to 500 mR for August 1-7 Worker #2 from 232 mR to 696 mR for August 1-7 Worker #3 from 40 mR to 160 mR for July Worker #4 from 48 mR to 192 mR for August 1-7 A Radiological Investigative Report (RIR) was initiated on August 14, 1986. The report was assigned number 039-86, and indicated that one of the workers (worker #2 above) had exceeded his assigned administrative limit of 1000 mrem / quarter. The RWP was reinstated on about August 19,

{ 1986 after adding the requirement that 0-200 mR and 0-500 mR SRD's are required both on the head and on the thig .0 Review of the Circumstances Leading to the Unplanned Exposure

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4.1 The root causes of the sequence of events leading to the unplanned I

exposure appear to have been a failure of communications between

, Maintenance Construction and Facilities (MCF) and Radiological Controls, and a failure on the part of Radiological Controls to identify the problem during their on-the-job surveys. Station procedure 105, Rev 25, i " Control of Maintenance", section 3.8.10 requires that the MCF Manager

Production ensure that ALARA reviews are obtained prior to work. Proce-dure 9300-ADM-4010.02, Rev 0, "ALARA Review Procedure", Section 7.1.1, specifies that the responsibility for initiating the pre-work ALARA review >

process rests with the department /section desiring to conduct the wor ;

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It is also the responsibility of the requestor to "... ensure all pertinent documents and information are made available to Radiological Controls in a timely manner". Furthermore, the job description should include as a minimum "... the exact location of the work". The responsibility for ensuring all the data required for an accurate ALARA review be provided to Radiological Engineering thus rests with the requesting department. In the case of the seal replacement job, the ALARA review, the radiological survey for the RWP, and the RWP were apparently all completed on the basis of incorrect understanding of the locations around the pump in which the workers were to stand during at least some phases of the work. As a result some of the workers were allowed to stand in unsurveyed areas around the recirculation pump and received doses higher than expecte The failure of the licensee to conduct a proper survey of the radiation hazards associated with the work constitutes an apparent violation of the requirements specified in 10 CFR 20.201. As a result of this failure, ,

appropriate personnel monitoring in accordance with 10 CFR 20.202 was not !

provided and an unplanned radiation exposure to one of the workers in excess of the licensee's administrative limits did occur. (50-219/86-28-01)

4.2 During work on the pump seal from July 30 to August 6,1986 Radiological Controls and MCF failed to notice that the RWP survey did not identify or quantify the radiation fields in which the workers actually stoo The first indication of a potential problem came when the chest and knee SRD's on one of the workers showed an unexpected discrepancy. It should be noted that procedure 915.9, Rev 3, " Implementation of the ALARA program" states that " Station supervisory personnel, working closely with Radio-logical Controls personnel, are responsible for reducing exposures by l planning activities of personnel who must enter radiation areas, by studying the actions and procedures of individuals, and by conducting post-operation debriefings on projects resulting in substantial exposures...". Although this general policy statement cevers planning, execution, and post-job reviews, specific implementation procedures, particularly 9300-ADM-4010.02, Rev 0, "ALARA Review Procedure", address the ALARA review pre- and post-job only. There appears to be no explicit requirements for reviews during job execution to ensure that the ALARA requirements are being implemented and that the accumulated doses are within the expected bound .3 Procedure 9300-ADM-1201.01, Rev 1, " Investigation of Radiological Incidents (RIR)" addresses the formal investigation and documentation of radiological incidents. The stated purpose of the procedure is to

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... assure adequate management involvement in identifying the causes contributing to radiological incidents and subsequently formulating and enforcing corrective measures". Based on the procedure criteria, the unplanned exposure incident in connection with the pump seal replacement job qualifies for an RIR. An RIR was generated by Radiological Engineering on August 14, 1986. However, contrary to the stated purpose of an RIR, this report only summarized the incident and stated that the corrective action was to use additional dosimetry. The encountered

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communication problems and on-the-job radiological survey inadequacies

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, 6 were not addressed in the RIR. The RIR report generated thus negated the stated purpose of such reports. Procedure 9300-ADM-1201.01 also calls for a critique panel to be convened and a. critique held within 5 days of the RIR date, unless an extension has been granted by the Radiological Controls Director / Deputy Director and noted on the RIR logsheet. One month after the date of the RIR, this had not been done. A formal cri-tique review is also required by procedure, but this had not been produced. These weaknesses in the RIR program will be reviewed in a future inspection. (50-219/86-28-02)

5.0 Exit Interview The inspector met with licensee representatives (denoted in paragraph 1)

at the conclusion of the inspection on September 11, 1986. The inspector summarized the scope of the inspection and the finding .