IR 05000254/1994013

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Insp Repts 50-254/94-13 & 50-265/94-13 on 940406-0630. Violations Noted.Major Areas Inspected:Radiological Control Program During 13th Cycle Refueling Outage
ML20149F547
Person / Time
Site: Quad Cities  Constellation icon.png
Issue date: 08/01/1994
From: Michael Kunowski, Steven Orth, Paul R, Perdrson C, Nirodh Shah
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20149F528 List:
References
50-254-94-13, 50-265-94-13, NUDOCS 9408110017
Download: ML20149F547 (12)


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l U.S. NUCLEAR REGULATORY COMMISSION i

REGION III

Reports No. 50-254/94013(DRSS); 50-265/94013(DRSS)

Docket Nos. 50-254; 50-265 Licenses No. DPR-29; DPR-30 Licensee:

Commonwealth Edison Company 1400 Opus P1 ace Downers Grove, IL 60515 Facility Name: Quad Cities Nuclear Generating Station, Units 1 and 2 l

Inspection At: Quad Cities Site, Cordova, Illinois i

Inspection Conducted: April 6 through June 30, 1994 Inspectors: (@

k R. A. Paul Date "

/T. A. U 7-2G-9V l

M. A. Kunowski Date I

h.A. k w k,/en 9-2 G 'l V N. Shah

Date fl. A. ((&Ef 9-2G-YY

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S. K. Orth Date

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D Approved By:

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CAthia D. Pederson, Chief Date

l feactorSupportProgramsBranch Date Inspection Summarv

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Inspection from April 6 throuah June 15. 1994 and Manaaement Meetina ort j

June 30. 1994 (Report Nos. 50-254/94013(DRSS): 50-265/94013(DRjl)1

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Areas Inspected: Routine announced inspection (Inspection Procedure (IP)

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83750) of the radiological control program during the Unit 1,13th cycle refueling outage (Q1R13) including, organization and management controls, i

external exposure and ALARA (as-low-as-reasonably-achievable) efforts,

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l internal exposure, contamination control, self-identification and correction of problems, and licensee actions on previous inspection findings.

I Results:

Radiological controls during the outage needed substantial improvement. Two examples of one violation were identified for inadequate surveys (Sections 8 and 10) and one violatien was identified for failure to 9408110017 940003

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follow the procedural requirement to label a container of a highly irradiated nuclear instrumentation component which could have led to a significantly higher than expected worker exposure (Section 11). The licensee also identified a relatively significant number of problems with radiation worker l

performance, particularly with following contamination control practices and radiation work permit requirements (Section 9).

In addition, planning and work control problems resulted in a dose total of over 230 person-rem (2.3 i

person-Sieverts) for the torus recoating project, compared to the pre-job estimate of 83 person-rem (0.83 person-Sievert).

In response to worker performance problems, a four-day work stoppage was instituted late in the outage by the licensee and a radiation work performance improvement plan was developed and implemented. This plan required a phased return to work with detailed job planning and oversight. At the Management Meeting, the licensee

discussed the problems that resulted in the work stoppage and findings of the j

l phased return to work. The actions to address the problems in radiological

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controls appeared substantial and appropriately focused.

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DETAILS 1.

Persons Contacted

+E. Kraft, Site Vice President

  • +G. Campbell, Station Manager

+R. Moravec, Site Engineering and Construction Superintendent G. DeBarey, Technical Services Assistant

+D. Winchester, Site Quality Verification Director i

l M. Hayse, Site Quality Verification Supervisor

+R. Baumer, Regulatory Assurance NRC Coordinator

  • +G. Powell, Lead Health Physicist, Technical

+A. Lewis, Assistant to the Station Manager

+M. Zinnen, Lead Health Physicist, Operating

  • +L. Tucbr, Technical Services Superintendent

+S. Sober, Health Physics Services Supervisor (HPSS)

  • +D. Bucknell, HPSS (acting)

+G. Tietz, Project Manager (torus work)

+T. Kroll, Maintenance Superintendent R. Gero, Bechtel Superintendent (Contractor)

+*N. Chrisotomos, Director Site Regulatory Assurance

+*D. Cook, Operations Superintendent

+M.

Pacilio, Site Construction

+P. Quealy, Lead Health Physicist, Technical (Dresden)

+F. Rescek, Director, Corporate Radiation Protection

+T. O. Martin, Deputy Director, Division of Reactor Projects, NRC Region III

+P. L. Hiland, Chief, Reactor Projects Section IB, NRC, Region III

  • +C. Miller, Senior Resident Inspector, NRC The inspectors also contacted other licensee and contractor employees.
  • Present at the Exit Meeting on June 15, 1994.

+ Present at the Management Meeting on June 30, 1994.

2.

Licensee Action on Previous Inspection Findinas (IP 83750)

(Closed) Violation No. 50-L54/93027-01: 50-265/93027-01:

Violation of Technical Specification (TS) 4.8.D.1, regarding the radiological environmental monitoring program (REMP). The licensee completed corrective actions, in addition to those documented in Inspection Report Nos. 254/93027(DRSS); 265/93027(DRSS). A program procedure (QCAP 610-1)

was revised to define the interface between the station point of contact (SP0C) and the program contractor and to require the SP0C to 1) verify the adequacy of new or modified sample locations, 2) ensure the Offsite Dose Calculation Manual reflected the location change, and 3) accompany

the contractor to the new location.

In a discussion with the inspector, the SP0C appeared familiar with the procedure changes.

NxNm tionAart, r'ethe REMF. h tm A docu errata fish and shorevent recurrenrequirement 3.8.0.2, which, ducting submitted anReport which ce.

in p (Closed) Viola detail th a

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f (Closed) Violation No. 50-254/93027-02: 50-265/93027-02:

Violation of TS 3.8.0.2, which, in part, requires that the annual report contain l

reasons for not conducting the REMP as required and plans for preventing recurrence.

The licensee submitted an errata for the 1991 Annual

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Radiological Environmental Operating Report which documented the I

deviations from the sampling program for both fish and shoreline sediments and adequately described methods to prevent recurrence.

Additionally, procedure QCAP 610-1 was revised to include a requirerrent

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l for reporting of deviations in the ann:s1 report in sufficient detail

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and documenting the actions for preventing recurrence.

l No violations or deviations were identified.

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Manaaement Oraanizatior, and Qualifications (IP 83750)

In May 1994, the individual who functioned as the radiation protection manager (RPM) and RP department head resigned. The RPM position was subsequently filled by the lead technical health physicist. This

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I individual has a degree in environmental health and over 10 years experience in reactor health physics, satisfying the TS requirements.

i The new RPM reports to the individual appointed as RP department head

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l (the Health Physics Services Supervisor (HPSS)). The HPSS position was filled with an individual with recent experience in the system engineering group.

In addition, the licensee stated that the station organization will be restructured to highlight the importance of RP by creating a health physics superintendent position that would report directly to the plant manager. Currently the RP department head reports to the Technical Services Superintendent, who reports to the plant

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manager. This planned reorganization will be reviewed during future inspections.

No violations or deviations were identified.

4.

External Exposure and ALARA (IP 83750)

The inspectors reviewed the progress of selected high dose jobs during the outage to ensure that adequate ALARA oversight and planning was ongoing. The progress of the chemical decontamination of the reactor recirculation system piping was also reviewed. Overall, the licensee's efforts were good (one exception was the torus recoating project discussed in Section 5 and Inspection Report Nos. 50-254/94010(DRP); 50-265/94010(DRP)).

To date, station exposure was about 892 rem (8.92 Sieverts (Sys)) compared to a goal of 1250 rem (12.5 Sys).

A crud burst early in the outage (Inspection Report Nos. 50-254/94005 (DRP); 50-265/94005(DRP)) resulted in dose rates for the main steam isolation valve (MSIV) work that were about a factor of two higher than estimated.

In response, the licensee pressure washed the valve internals, added shielding, and relocated work to lower dose rate areas.

Also, work scope for the inboard MSIVs, where the highest dose rate increase was seen, was reduced.

In addition to the dose rates, other problems noted by the inspector were the lack of a dedicated,

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experienced ALARA planner for the job and the lack of a realistic accumulated dose estimate based on the increased dose rates.

The dose total for the job was about 56 person-rem (0.56 person-Sv), close to the pre-job estimate.

The dose rates for the control rod drive (CRD) work also increased because of the crud burst, but also because the vessel inventory was reduced about 4000 gallons more than in previous outages. The ALARA planner recognized some increases in dose rates but did not recognize the overall magnitude. Once the initial batch of CRDs were removed, the ALARA planner identified that instead of the targeted 262 millirem (mrem) (2.62 mSv) per drive, 328 mrem (3.28 mSv) per drive was being accumulated. The job was stopped and a team was formed to evaluate means to reduce doses. Subsequent actions resulted in a total job dose of 4.9 rem (49 mSv), below the goal of 6.3 rem (63 mSv).

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For the recirculation piping decontamination, a vendor performed a i

three-step process which effectively reduced the average dose rates at t

the recirculation risers from about 1.2 rem (12 mSv)) per hour to about 0.125 rem (1.25 mSv) per hour. This activity appeared to be well coordinated, and areas of higher than normal dose rates were controlled by the licensee. The chemical decontamination is viewed as a good

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initiative to reduce dose; however, its effectiveness was diminished by

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the crud burst.

No violations or deviations were identified.

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5.

Torus Recoatina Pro.iect (IP 83750)

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The licensee re-scheduled a project to recoat the inside of the torus I

from Q1R14 to the current Q1R13 as a result of concerns expressed during i

the NRC Diagnostic Evaluation Team (DET) inspection in November 1993.

Planning for the project was reviewed before the outage (NRC Inspection Report Nos. 50-254/94002(DRSS); 50-265/94002(DRSS)), but the inspection i

failed to identify any problems. The original dose goal for this

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project was about 83 rem (0.83 Sv) based on dose rates for putatively similar projects at two other stations and work-hour estimates submitted from the main contractor. With only the demobilization of equipment remaining, the dose total for the project was about 230 person-rem (2.3 t

i person-SV).

The projects at the other stations were not as similar to the Quad Cities project as originally believed and the full scope of the Quad Cities work was not known at the time the work-hour estimates were made.

In addition, a full-time person was hired to provide ALARA planning and oversight of the project and to coordinate activities between the contractor and site personnel; however, this person resigned shortly before the majority of the work began. After the torus was drained, gereral area dose rates ranged between 90-100 mrem (0.9-1 mSv)/hr, about four times higher than expected. The dose rates were attributed to sludge at the bottom of the torus, but subsequent desludging activities, from March 16-25, 1994, failed to reduce dose rates. Although

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cumulative exposure was already 38 rem (0.38 Sv) and dose rates remained higher than expected, work continued without a reassessment by station management. A sudden increase in personnel contamination and radiological intake events may have diverted station management attention from the steadily increasing external dose total of the project.

Following discussions between NRC and station management on April 7, the dose goal was revised to 310 rem (3.1 Sv), a project manager was designated, and, on April 12, a three-day work stoppage occurred to reexamine ALARA concerns.

In addition, an assessment of the project ALARA planning was conducted by a four-person team led by a

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senior corporate health physicist. A report of that assessment was reviewed by the inspectors and found to be cogent and candid.

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appeared that the assessment was done well.

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Inadequate planning and management involvement were the root cause of the poor radiological performance during the project.

Contributing causes included insufficient time provided for planning, no management reevaluation of the project after the higher than expected dose rates,

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and use of mostly inexperienced radiation workers (painters and blasters) without sufficient mock-up training. According to the licensee, these weaknesses will be addressed in the outage critique and

used to plan an upcoming recoat of the Unit 2 torus.

Planning for the

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Unit 2 project will be reviewed during future inspections (Inspection Followup Item (IFI) No. 50-254/94013-01(DRSS); 50-265/94013-01(CRSS)).

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No violations or deviations were identified; however, a significant weakness in ALARA planning of a high dose job was identified.

6.

Control of Radioactive Materials anLContamination (IP 83750)

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About 284 personnel contamination events (PCEs) were accrued to date, exceeding the outage goal of 190. The poor performance was attributed to the torus work, which accounted for about 116 PCEs. After a four-day work stoppage and a phased return work (Section 9 and Inspection Report Nos. 50-254/94014(DRP); 50-265/94014(DRP)), the incidence of personnel contamination events decreased.

During plant tours (Section 12), the inspector observed several examples

of declining housekeeping. Miscellaneous debris was noted in several contaminated work areas in the reactor buildings and the Unit I drywell,

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suggesting that further management attention was warranted. Addition-ally, standing water was observed in several torus corner rooms of both Units. Although the water was primarily from ground seepage, equipment drainage during maintenance was a contributing factor.

An inspector also reviewed the practice of removing laundry bags of contaminated protective clothing from within posted, contaminated areas.

An RP shift supervisor (RPSS) indicated that personnel removing the bags

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had the discretion to " double bag" them based on laundry bag material condition. The person removing the bag was required to measure the dose rate, but contamination surveys were only necessary if the bag was torn, wet, or contamination was suspected.

For bags having dose rates in

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l excess of 25 mrem (0.25 mSv)/ hour, additional instruction and/or assistance by the RP staff was required.

Personnel wore liners and gloves while handling the laundry bags and attended the bags while they were transported. The RPSS indicated that the station had not l

experienced contamination control problems from this practice.

The inspector discussed the practice with a member of the training staff, who indicated that it was consistent with the training on this subject.

As there was no history of contaminations stemming from laundry removal, i

the practice appeared to be acceptable.

The inspectors also reviewed two events concerning the release of low level (<5000 disintegrations per minute (dpm)/100 centimeters * (cm*))

material from the radiologically posted area (RPA), but not outside the protected area. One item.. a digital pressure indicator (about 5,000 dpm/100 cm"), was found dt. ring a routine survey of areas outside the l

RPA.

It had apparently n)t been surveyed prior to release from the RPA.

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The second item was a pol,tethylene tank (2,000 dpm/100 cm* (internal)

and 5,000 dpm/100 cm* (bottom external surface)) which was inadvertently released because of miscom m ication between the RP and maintenance l

departments. Although individually of minor safety significance, these events represent a continuing decline in the control of contaminated

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material warranting increased management attention.

No violations or deviations were identified.

7.

Internal Exposure Control (IP 83750)

l During this outage the revised 10 CFR Part 20 requirements were fully implemented, with the focus on reducing workers' total effective dose equivalent (TEDE) to as-low-as-reasonably-achievable (ALARA). A part of this involved reducing the use of respirators where respirator use to prevent a small dose from internal contamination could result in an higher external dose. The inspector reviewed this effort and with the exception of a few weaknesses noted below the program appeared sufficient to maintain the TEDE ALARA.

Early in the torus recoating project, numerous personnel contaminations and intakes occurred. One specific weakness noted by the inspector in the TEDE/ALARA evaluation done to support the reduced use of respirators was that the torus dried more rapidly than expected and the type and extent of the contamination was not known.

In addition, a general program weakness was identified in the respiratory protection evaluation procedure, because it did not require a TEDE/ALARA evaluation when engineering controls were used. This weakness contributed to the intake event described in Section 8.

These weaknesses were discussed with the licensee.

Corrective action for the specific weakness will be included in the planning for the Unit 2 torus recoating project (Section 5). The corrective action for the general program weakness will be reviewed during a future inspection (IFI No. 50-254/94013-02(DRSS); 50-265/94013-02(DRSS)).

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l No violations or deviations were identified; however, weaknesses were identified in exposure control.

8.

Intake of Radioactive Material (IP 83750)

On April 20, 1994, a contract worker lapping a valve disc in the drywell received an intake of about 1585 nanocuries (nCi) (58.6 kiloBecquerels

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(kBq)) of cobalt-60 and 1M nCi (3.9 kBq) of manganese-54. The worker's assistant, who was working about 2-3 feet away, did not receive an intake. An investigation of the intake was conducted by a corporate health physicist concurrently with the NRC review and had similar

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findings.

These are discussed below. The licensee estimated that the l

l comaitted effective dose equivalent (CEDE) was 100 mrem (1 mSv) and the TEDE was about 250 mrem (2.5 mSv), about 5% of the allowable limit. The

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inspectors verified both values.

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Although the valve was highly contaminated, the workers did not wear respirators because:

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air samples taken during the valve breach and other non-l lapping work indicated no elevated airborne activity, and b.

RP assumed as part of the ALARA evaluation that keeping the valve wet and using engineering controls (a 500-cubic feet per minute high efficiency particulate air (HEPA) unit was set up near the disc) would minimize airborne activity.

In addition to a set of cloth protective clothing, the workers wore rubber gear, dust masks, and face shields.

Before the job, the HEPA hose was placed close to the designated setup area and an air sampler was placed about two feet above that location. The air sample results indicated an airborne concentration around 73 Derived Air Concentrations.

The root cause of the intake was the failure to evaluate the concentrations of airborne radioactive material under actual working conditions. This evaluation (survey) was necessary to show compliance with the annual dose limits in 10 CFR 20.1201. The failure to evaluate is an example of a violation of 10 CFR 20.1501(a) which requires, in part, such evaluations (surveys) as may be necessary to comply with the requirements of Part 20 (Violation No. 50-254/94013-03a(DRSS); 50-265/94013-03a(DRSS)). Although this problem was identified by the licensee and extensive corrective actions were taken (Section 9), a similar problem occurred late in 1993 (Section 5 of Inspection Report Nos. 50-254/94002; 50-265/94002), but apparently corrective actions for that problem were not effective.

Specific problems with the job or contributing causes identified by the inspector included:

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the pre-job ALARA evaluation did not account for the worker repositioning himself and the HEPA unit as he worked;

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the RPT providing intermittent coverage was not involved in the original ALARA evaluation, was not aware of the magnitude of the valve contamination, nor noticed during the periodic visits to the job the re-positioning of the worker and the HEPA hose;

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the lack of short term air sampling and analysis (by grab samples or continuous air monitor) precluded early identification of the changing conditions;

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an assumption was made that similar work had been performed successfully without respirators and that the engineering

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controls were sufficient to prevent an airborne hazard; and

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the HEPA setup was not t sted prior to use.

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Additionally, in general, the implementation of the revised Part 20 did not appropriately account for the effectiveness and use of engineering l

controls in conjunction with decreased reliance on respiratory

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p mtution devices. The licensee acknowledged this observation.

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matter will be reviewed during future inspections.

l An example of a violation was identified.

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9.

Radiation Worker Performance Problems (IP 83750)

In a positive move, the licensee recently increased its efforts to document self-identified problems with compliance with RP requirements.

These problems were recorded on forms referred to as problem identification forms (PIFs). A relatitely significant number of the PIFs documented problems with workers rallowing good contamination control practices and the requirements of radiation work permits (RWPs).

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In tc-., the PIFs reviewed by the inspector and the licensee, as part of a team review of 50 RP-related PIFs, indicated that worker adherence to radiological procedures in general needed significant improvement.

The licensee recognized this and took corrective actions, which included initiating a four-day work stoppage, development of a radiation work performance improvement plan, and a phased return to work. These actions wera discussed with the licensee at a Management Meeting (Section 13).

Based on inspector review and discussions at the meeting, it appeared that station management had taken a strong, well thought-out stance to correct RP performance problems.

An example of the licensee's emphasis on adherence to RP requirements was seen shortly after the work stoppage was lifted when a first-line supervisor was fired for improperly crossing a contaminated area boundary. The final results of the team PIF review and the status of the improvement plan will be reviewed during a future inspection (IFI No. 50-254/94013-04(DRSS); 50-265/94013-04(DRSS)).

No violations or deviations were identified.

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10.

Control of Hiah Radiation Areas (IP 83750)

On May 13, 1994, a contract worker entered the #2 dust collector tent inside a locked high radiation area on the 623' elevation of the Unit 1 Reactor Building without a survey having been performed. The worker was performing a routine check of equipment and had been accompanied on initial entry into the area by an RPT who conducted a survey and then

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left the area. However, the need to enter the tent was never communicated nor understood by the RPT and a survey was not done. After finishing his work in the surveyed area, the worker entered the tent, where his electronic dosimeter (ED) alarmed. He immediately left the

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tent and notified the RPT. A subsequent survey identified a general area dose rate of 3.6 rem (36 mSv)/hr, which exceeded the worker's ED

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setpoint of 2 rem (20 mSv)/hr. Corrective actions included counseling the worker and the RPT about the need to ensure that a complete description of a job is communicated and understood.

This survey was necessary to show compliance with the annual dose limits in 10 CFR 20.1201. Failure to perform a survey is an example of a violation of 10 CFR 20.1501(a) which requires, in part, such surveys as may be necessary to comply with the requirements of Part 20 (Violation No. 50-254/94013-03b(DRSS); 50-265/94013-03b(DRSS)). Although this problem was identified by the licensee and extensive corrective actions

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were taken (Section 9), a similar problem occurred in late 1993 (Section

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5 of Inspection Report Nos. 50-254/94002; 50-265/94002), but apparently corrective actions for that problem were not effective.

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An example of a violation was identified.

11.

Failure to Properly label Container of Radioactive Material (IP 83750)

On June 8,1994, a contract worker, with several other involved workers

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l nearby, was moving a bucket of jet pump parts in the flooded reactor

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cavity (via a rope tied to the handle) when he apparently, brought it too close to the surface, causing his ED to alarm. An RPT in the area immediately stopped work and secured the bucket. An examination of the l

parts in the bucket identified a four-inch section of the spring plunger

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assembly of an intermediate range or source range monitor. This section had apparently been inadvertently left in the bucket on May 20, 1994, after it broke off during removal of the monitor.

The licensee subsequently determined the near-contact dose rate reading of the plunger assembly was about 5170 rad (51.7 Gray)/hr. The highest dose rate measured by the worker's ED was 167 mrem (1.67 mSv)/hr and his dose for the entire shift was less than 5 mrem (0.05 mSv), consistent with his previous shifts.

The root cause was personnel error in that the bucket was not labeled after it was moved earlier on June 8 from the spent fuel pool (SFP),

where it had been tied off five feet below the surface, to the reactor cavity, where it was tied off to the handrail. The RPT involved in the earlier move indicated to the inspector that he did not believe a label

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l on the rope would be useful, because the radiological hazard for an

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object submersed in the SFP or cavity could increase significantly after t

a survey was conducted and a label was applied. A fuel handler involved in the earlier move indicated to the inspector that he was unaware of the fuel handling procedure requirement to label the rope.

Interim procedure 670, " Refueling Pool Inventory Control," required, in part, that radioactive equipment or items stored in the refueling cavity that can cause a whole body exposure >100 mrem (>l mSv)/hr and are readily accessible must be conspicuously labeled to warn personnel of the radiation hazard.

Failure to label the container as required by the procedure is a violation of Technical Specification 6.3 which requires, in part, adherence to radiation protection procedures (Violation No. 50-(

254/94013-05(DRSS); 50-265/94013-05(DRSS)). The licensee's response to this self-identified event was swift and extensive, and provided a major impetus to the work stoppage discussed in Section 9.

However, this violation did not meet the NRC criteria for non-cited violations because actions taken around March 1994 after the resident inspector raised a concern about the labelling of materials tied off in the SFP should have prevented the June 8th event.

One violation was identified.

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Plant Tours (IP 83750)

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l The inspectors toured the Unit I drywell, torus corner rooms, and the turbine and reactor buildings. Radiological postings were consistent with 10 CFR 20 requirements and protective clothing storage areas were in good coru '? ion. The inspectors also verified through interviews,

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l that workers were familiar with radiological concerns discussed in pre-job briefings and with work area radiological conditions.

Confirmatory measurements taken by the inspectors were in good agreement with licensee values. Average dose rates in the drywell were relatively high (100-200 mrem (1-2 mSv)/hr) because of the crud burst. Drywell access point controls appeared good with the use of cameras and an ED telemetry system to monitor work activities. Several deficiencies regarding housekeeping and contamination control are discussed in Section 6.

No violations or deviations were identified.

13.

Exit and Manaaement Meetinas The scope and findings of the inspection were reviewed with the licensee representatives (Section 1) at the conclusion uf the inspection on June 15, 1994. The licensee did not identify any documents as proprietary. The following matters were specifically discussed by the inspectors:

outage performance (Section 4),

poor planning of the torus recoating project (Section 5),

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worker adherence to procedures (Section 9),

violations concerning inadequate surveys (Sections 8 and 10) and

failure to label a container of radioactive material (Section 11),

and observations made during plant tours (Section 12).

  • On June 30, 1994, a Management Meeting was held at the station between NRC and station personnel (Section 1) to discuss the need for

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significant improvement in the radiological cortrols program. The licensee discussed the status of the corrective actions taken to data, including the four-day work stoppage, development of a radiation work performance improvement plan, and a phased return to work. These actions have apparently heightened worker and manager awareness of RP; identified problems in the RP program and in other areas; and highlighted the benefits of good pre-job briefings and turnovers.

It appeared that station management had taken a strong, well-thought out stance to correct RP performance problems.

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