IR 05000254/1994023
| ML20024J232 | |
| Person / Time | |
|---|---|
| Site: | Quad Cities  |
| Issue date: | 09/28/1994 |
| From: | Gill C, Michael Kunowski, Pederson C NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20024J230 | List: |
| References | |
| 50-254-94-23-EC, 50-265-94-23, NUDOCS 9410130024 | |
| Download: ML20024J232 (13) | |
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U. S. NUCLEAR REGULATORY COMMISSION-l i
REGION III
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Reports No. 50-254/94023(DRSS); No. 50-265/94023(DRSS)
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Docket Nos. 50-254; 50-265 Licenses No. DPR-29; No. DPR-30 Licensee:
Commonwealth Edison Company
Executive Towers West III l
1400 Opus Place - Suite 300 Downers Grove, IL 60515
Facility Name: Quad Cities Nuclear Station, Units 1 and 2 Meeting Conducted:
September 23, 1994 Meeting Location:
U. S. Nuclear Regulatory Commission i
Region III Office
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801 Warrenville Road
Lisle, IL 60532 l
Type of Meeting:
Enforcement Conference Inspection Conducted: August 15 through 25, 1994 Inspectors:
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C. F. Gill, Senior Radiation Specialist Date
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M. Kunowski, Senior Radiation Specialist Date Approved By:
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i gynthiaD.Pederson, Chief Date ' '
(jReactorSupportProgramsBranch Meetina Summary Enforcement Conference on September 23. 1994 (Recorts No.50-254/94023(DRSS):
No. 50-265/94023(DRSS))
Areas Discussed:
Enforcement conference to discuss the circumstances
of the possible radiation exposure of the skin of a female worker on August 8, 1994, in excess of the 50-rem regulatory limit. Two apparent violations from Inspection Reports No. 50-254/94021(DRSS) and No. 50-265/94021(DRSS) were specifically addressed:
(1) use of radioactive material in a manner not authorized by the license, and (2) inadequate survey of the female worker when she first attempted to leave the radiologically posted area, contrary to 10 CFR 20. The licensee's final skin dose estimate to the worker for the event was 22.17 rem (0.2217 Sievert (SV)), assuming the radioactive side of the source faced the skin of the worker and an exposure time of 12 minutes and 23 seconds. Her cumulative skin dose for the year was 23.83 rem (0.2383 Sv).
The corrective actions for the event were comprehensive.
NRC management indicated that this event was another example of workers failing to implement management expectations and regulatory requirements, similar to other recent-problems in radiation protection and foreign material exclusion.
9410130024 940930 PDR ADOCK 05000254
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DETAILS 1.
Persons Present at the Enforcement Conference Commonwealth Edison Company S. Perry, Senior Vice President, Boiling Water Reactors E. Kraft, Site Vice President G. Campbell, b-it Manager N. Chrissotimos, Regulatory Assurance Supervisor R. Baumer, NRC Coordinator D. Bucknell, Radiation Protection Supervisor A. Lewis, Special Assistant to Plant Manager G. Powell, Radiation Protection Manager L. Tucker, Technical Services Superintendent
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J. Morris, Executive Assistant to the Site Vice President K. Hostert, Training Supervisor R. Porter, General Foreman, Radiation Protection, Dresden D. Zuidema, A-Mechanic, Mechanical Maintenance D. Winchester, Site Quality Verification D. Goldsmith, Health Physics Supervisor, Byron F. Rescek, Radiation Protection Director, Corporate i
G. Edgar, Attorney J. Schrage, Nuclear Licensing Administrator D. Jenkins, General Attorney G. Wald, Nuclear Communications Administrator P. Laird, Security Director, Corporate M. S. Nuclear Reaulatory Commission J. B. Martin, Regional Administrator H. J. Miller, Deputy Regional Administrator W. L. Axelson, Director, Division of Radiation Safety and Safeguards
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T. O. Martin, Deputy Director, Division of Reactor Projects C. D. Pederson, Chief, Reactor Support Programs Branch P. L. Hiland, Chief, Reactor Projects Section IB P. R. Pelke, Enforcement Specialist R. A. Capra, Project Director, Office of Nuclear Reactor Regulation (NRR)
R. M. Pulsifer, Project Manager, NRR J. E. Wigginton, Chief, Facilities Radiation Protection Section, NRR N. Shah, Radiation Specialist J. M. Bell, Health Physicist, NRR R. J. Strasma, Senior Public Affairs Officer J. R. Creed, Chief, Safeguards and Incident Response Section R. W. DeFayette, Director, Enforcement and Investigation Coordination Staff J. E. Beall, Enforcement Specialist, Office of Enforcement B. A. Berson, Regional Counsel C. F. Gill, Senior Radiation Specialist C. G. Miller, Senior Resident Inspector M. A. Kunowski, Senior Radiation Specialist
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2.
Enforcement Conference
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An enforcement conference was held in the NRC Region III Office on September 23, 1994, to discuss the circumstances of the possible
radiation exposure of the skin of a female worker on August 8,1994, in
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excess of the 50-rem regulatory limit. The two apparent violations from Inspection Reports No. 50-254/94021(DRSS) and No. 50-265/94021(DRSS)
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were specifically addressed: (1) use of radioactive material in a manner i
not authorized by the license, and (2) inadequate survey of the female
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worker when she first attempted to leave the radiologically posted area, i
contrary to 10 CFR 20.
l The licensee's final dose estimate for the worker from the source was
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22.17 rem (0.2217 Sievert (Sv)), shallow dose equivalent, and 79
millirem (0.79 mSv), deep dose equivalent. The assumptions for this dose estimate were that the radioactive side of the source faced toward
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the skin of the worker's right buttock, thare wa.s no air gap between the source and her skin for 58 seconds of the 12 minute and 23 secor.d
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exposure, and there was a 1 centimeter air gap for the remainder of the i
exposure. The dose was based on licensee data from thermoluminescent dosimeters.
This estimate appears reasonable, but implied more accuracy than is possible given the uncertainties in time-line construction and measurements of air gaps in clothing. With the inclusion of the
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worker's previous exposure of 1.58 rem (0.0158 Sv) dose equivalent, her 23.83 rem (0.2383 Sv) total for the year is below the 50-rem regulatory
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limit.
If the radioactive side of the source had been-facing away from her skin while it was in her pocket, the estimated dose from this event was 2.3 rer F.023 SV), shallow dose equivalent. According to the i
licensee, has now been allowed back in the radiologically posted
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area (RPA)
The licensee described corrective actions (see attached copy of the Commonwealth Edison Company presentation material) taken or planned for l
the violations. These actions included conducting an extensive investigation involving corporate security personnel and the U.S. FBI,
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removing all similar Sr-90 sources from general access areas at all i
Commonwealth Edison sites, revising and providing training on the
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procedure used by radiation protection technicians for surveying i
contaminated personnel, and upgrading contractor orientation, new station employee training, and refresher training. These actions i
appeared comprehensive.
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At the conclusion of the conference, NRC management stated that this
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action should not be construed as an isolated event, but rather another example of workers failing to implement management expectations and
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regulatory requirements, similar to other recent problems in radiation protection and foreign material exclusion.
Attachment:
Commonwealth Edison Con,pany Presentation Material
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SEPTEMBER 23,1994 QUAD CITIES ENFORCEMENT CONFERENCE RADIOACTIVE SOURCE EVENT AGENDA I.
INTRODUCTORY REMARKS
..... E. Kraft
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II.
SECURITY INVESTIGATION SUMMARY P. Laird
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SEQUENCE OF EVENTS AND APPARENT VIOLATIONS
. A. Irwis
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SAFETY SIGNIFICANCE..
. G. Powell
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LEVEL 2 INVESTIGATION AND CORRECTIVE ACTIONS
.... A. Lewis
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VI.
CONCLUSIONS / CLOSING REMARKS
.. E. Kraft
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RADIOACTIVE SOURCE EVENT I. INTRODUCTORY REMARKS
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Agerda e
Objectives: To demonstrate Comed understanding of:
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The event, causes, and current state of applicable porti]ns of radiation protection program at Quad Cities Station.
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The safety and management significance and corrective / preventive actions.
- Comed response to evidence of deliberate misconduct
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Aggressive corrective / preventive actions based upon worse set of conditions.
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Immediate action to bring this matter to the attention and under jurisdiction of
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the FBI.
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RADIOACTIVE SOURCE EVENT II. SECURITY INVESTIGATION - Pat Laird
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RADIOACTIVE SOURCE EVENT III. SEQUENCE OF EVENTS TIME LINE 8/8/94 The Bechtel laborer was assisting contract carpenters with erecting scaffolding in the turbine building.
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11:44 The worker left the turbine building for lunch dressed in personal clothing including the blue jeans which were later found to contain the strontium source.
The worker exited the radiation area on the north end of the turbine building passing through the IPM-8 personnel monitors at trackway 2 (TW-2) without an alarm, indicating the source was not in the worker's pocket at that time.
12:42 The worket re-entered the building at TW-2 and walked to a change area at the south end of the turbine building and changed into blue work coveral!s.
The worker left the personal clothing including the blue jeans at the change area on the ground floor of the turbine building. The worker exited the turbine building for a pre-job briefing in the service building and then re-entered to begin work on the main turbine floor.
14:54 The worker re-entered the turbine building at TW-2 after a break, proceeded to the change area, donned personal clothing, and returned to TW-2 to exit the building. The worker alarmed the IPM-8 personnel radiation monitor required to leave the radiation area.
The worker immediately contacted tne radiation protection technician (RPT-1)
stationed at TW-2. RPT-1 observed the worker repeat the IPM-8 monitoring
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and checked the front of the worker with a hand held geiger mueller detector (GM), in an effort to isolate the contamination.
After RPT-1 confirmed the presence of contamination, the worker was sent to TW-1 at the south end of the turbine building where personnel decontamination is normally handled and documented.
15:34 The worker contacted the RPT-2 stationed at TW-1 and informed RPT-2 of the alarms at TW-2. RPT-2 took the worker to :m IPM-8 monitor at TW-1 which
.went into. unit. fault..RPT-2.made another. attempt with a different TW-1 IPM-8 monitor which also went into a unit fault. RPT-2 then used a GM to i
check the worker and the GM pegged off scale over the back pocket.
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RADIOACTIVE SOURCE EVENT III. SEQUENCE OF EVENTS (Continued)
About 15:37 RPT-2 made two attempts to remove a suspected hot particle from the back pocket with masking tape and then escorted the worker to the personnel decontamination room where the worker removed personal clothing and donned a paper suit ending the worker's exposure to the source.
About 15:37 RPT-3 arrived and escorted the paper suited worker to an IPM-8 monitor at TW-1 and the worker passed with no alarm.
About 15:45 RPT-2 and RPT-3 called for a Radiation Protection supervisor and Health
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Physicist (HP) and then began to check the clothing with a GM, finding elevated readings on the blue jeans. RPT-3 was checking the blue jeans when the HP arrived. RPT-3 turned the jeans upside down and a dime shaped object fell out of the right rear pocket which the HP identified as a Sr-90 calibration source from a plexiglass fan source. These fan sources are located in various locations throughout the plant to response check dose rate instruments. The HP directed RPT-4 to check these fan sources to locate the origin of the detached source.
About 16:00 RPT-4 determined that the source originated from a source holder attached to a supply cabinet on the main turbine floor.
08/09/94 The radiation protection department re-enacted the chain of events with the exposed worker over three trial runs and determined an estimated exposure time of about 12 minutes from the time the pants were removed.
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O RADIOACTIVE SOURCE EVENT
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III. APPARENT VIOLATIONS 1)
Unauthorized use of licensed material under license condition number 2.D which authorizes the licensee, in part, to receive, possess, and use at any time, any byproduct, source, and special nuclear material, as necessary to perform reactor instrumentation and radiation monitoring equipment calibrations, and as fission detectors, pursuant to the Atomic Energy Act of 1954, as amended, and 10 CFR 30, 40, and 70.
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10 CFR 20.1501, which states in part, that the licensee shall make or cause to be made such surveys which are reasonable under the circumstances to evaluate the extent of radiation levels and the potential radiological hazards present.
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a RADIOACTIVE SOURCE EVENT IV. SAFETY SIGNIFICANCE Initial Assessment - The assessment was conducted in order to provide a
conservative dose value to guide immediate corrective action and licensee response.
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Upon determination of the radioactive source as Sr-90, the Station immediately initiated a dose assessment and restricted RPA access for the affected individual. This initial assessment was completed approximately 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> after discovery of the source, and resulted in a bounding dose of 30 rem SDE. The initial dose assessment assumed that the most active side of the source faced the individual's skin. This assumption was carried through all subsequent analyses. In addition, the Resident Inspector and Corporate Radiation Protection were notified of the event approximately four hours after the discovery of the source.
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Follow-up dose assessments initiated on the day after the event utilized both company and outside experts. At approximately 3:00 p.m. on August 9, (23 hours2.662037e-4 days <br />0.00639 hours <br />3.80291e-5 weeks <br />8.7515e-6 months <br /> after discovery of the source), the bounding dose estimate was revised and the Station could no longer mle out a dose greater than 50 rem SDE. Because a dose greater than 50 rem could not be ruled out, the Stat, ion notified the NRC at 6:57 p.m. on August 9, 1994, via the ENS Notification System. The Station then continued efforts to revise the dose assessment.
Additional Assessments - Additional dose analyses were performed with more
precise source geometry data and utilizing three industry-accepted analytical models.
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A final dose assessment of 22.17 rem SDE was assigned to the individual, based upon the results of the three analytical models.
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The final dose value was the most conservative value of the three analytical models. Ilowever, the results of all three analytical models were within 127c of each other.
The. event is highly.significant from both management and radiation protection
program standpoints.
The Station has developed a dose assessment methodology for the individual
who took deliberate action. The dose assessment will be performed when, and if. enough information is available.
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RADIOACTIVE SOURCE EVENT V. LEVEL 2 INVESTIGATION AND CORRECTIVE ACTIONS
Investigation Focus
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Initiated 09/09/94 at the direction of the Station Manager
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Identification of Causes
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Immediate and Long Term Corrective Actions
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Parallel Corporate Security Investigation
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Root Cause: External Human Factor, Deliberate Action by Individual
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Contributing Causes Design Configuration and Location of Source Holder
Inappropriate Assumptions leading to Ineffective Initial Survey
Training / Qualification l
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RADIOACTIVE SOURCE EVENT V. LEVEL 2 INVESTIGATION AND CORRECTIVE ACTIONS CORRECTIVE ACTIONS COMPI ETED ACTIONS Initiated security investigation and FBI involvement.
- All Sr-90 check sources removed from unrestricted use in the plant.
- Sources inventoried and evaluated.
- Briefing for RPT's on guidance for response to contamination events.
- Incorporation of contamination event response guidance in procedure.
- Article in station newspaper on expectations for employee conduct.
- Contractor Orientation and New Station Employee Training.
- Informed management at all sites.
- PLANNED ACTIONS Site-wide evaluation of radiological hazards.
- General Employee Training (GET) enhancements.
- Upgraded controls for sources.
- Lessons-learned from Quad Cities will be provided to all Comed sites, and
system-wide enhancements will be undertaken for source control, surveys by RPTs, and training.
Site V.P.'s at all Comed sites will issue letters reinforcing expectations
concerning radiation work practices, respect for radiation, employee conduct, and respect for co-workers.
ACTIONS TO REINFORCE MANAGEMENT EXPECTATIONS ADM\\RSLENFCF WPF
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RADIOACTIVE SOURCE EVENT VI. CONCLUSIONS AND CLOSING REMARKS We regard this event with utmost seriousness. We will not tolerate conduct
which shows such blatant disrespect for radiation and fellow workers. Our actions to engage and assist the FBI demonstrate our concern and commitment to obtain accountability.
We have developed and will pursue exhaustive corrective and preventive
actions. We believe we have taken all reasonable steps to tighten our program.
Since May, we have undertaken a major effort to emphasize and upgrade our
radiation protection program. Our stand-down got us started, and our improvement program is underway and on-course. Although we have some distance to go with our improvement program, we see this event as an isolated case which is not indicative of the current state of our program, or a breakdown in that program. This was not the result of a worker taking shortcuts, or a workaround, or a lack of understanding of radiological work practices. At the same time, we see the event as an opportunity to adjust our program and seal any gaps that may persist.
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