IR 05000266/1990012

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Enforcement Conference Repts 50-266/90-12 & 50-301/90-12 on 900525.Violations Noted.Major Areas Discussed:Licensee Apparent Recurrent High Radiation Area Barrier Violations & Weaknesses in Radiation Protection Program
ML20055J376
Person / Time
Site: Browns Ferry, Point Beach  Tennessee Valley Authority icon.png
Issue date: 06/08/1990
From: Snell W
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20055J374 List:
References
50-266-90-12-EC, 50-301-90-12, NUDOCS 9008020165
Download: ML20055J376 (43)
v • d • e


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- 1 w ' . . , . U.S. NUCLEAR' REGULATORY COMMIS.SION ,,-

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Reports No? 50-266/90012(DRSS); 50-301/90012(DRSS) -EA1No. 90-099- x >

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' ,. . ' Docket No. 50-266;:50-301 , Licensfs' No. DPR;24;; DPR-27L s .

1[, tLicenseei?. Wisconsin Electric Power Company

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p , fFacility NameE Poi.nt Beach Nuclear; Plant (PBNP), Units 1 and 2 ,

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! Me' ting' Location: 33NRC Region III'0ffice, Glen Ellyn, Illinois 6 . . ,

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Meeting Conducted: May 25,"1990 v, .,,

A rType of Meeting: Enforcement Conference f,

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{ApprovedByi . [ 2 td. Uf G/8/Jo W. G.<Snell, C1ief

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Radiological Controls.and: ,

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Meeting' Summary 'i '

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Meetinin on May. 25,'1990 (Report No. 50-266/90012(DRSS); 50-301/90012(DRSS))

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Areas Discussed:-J An enforcement conference was conducted to discuss the

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  1. weaknesses in-the? radiation. protection program Mch were identified as M t, # , , 3 result ~of a hot particle event' on April' 3,19e .

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Results: Two Severity. Level IV violations of' regulatory requirements were f '> '

identified:e (1)1 failure to. meet technical specification requirements regarding

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Lhigh-radiation area * entry control procedural adherence, and (2) failure- to

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make an' adequate (timely) evaluation of ;the dose received after an individual handled la: fuel fragment),j A third' violation, failure to have~ approved-

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radiological control tprocedures for the collection and handling of highly -

radioactive' particles,available for station ' personnel met the criteria for.the exercise of discretion of Section V.G.I. of Appendix C to Part 2, therefore,la Notice of Violation was not issue ~

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Wisconsin Electric Power Company . .

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Fay,,ViceP[e'sident,'HuclearPower  ; ,

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. D. Johnson _,, Superintendent,vHuclear Regulation . . .

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R. Seizert, Superintendent { Regulatory and Support Services , l,

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  • 5 C. Paperiello, Deputy,Regionali Administration -

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. C. Norelius, Direct % Division of Radiation Safety and Safeguards '

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'R. Greger,:Chiefi Reactor' Programs Branch .

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' Jackiw,' Chief;;Reacto'r ProjectseSection 3A .

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'W.nSnell,'ChiefpRadiological Contro.ls and Emergency Preparedness Section-

, , C. Vanderniet,' Seni'or < Resident.. Inspector.-Point Beach i w

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W. Grant, Senior l Radiation Specialist

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A. ,Markley, Radiation > Specialist" 1 o

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20 Weilg Enforcement?Specialistj

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,  ? M.' Kunowski, Radiation? Specialist >

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As.a' result of

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? .4 apparent violations of NRC regulatory requirements,Ianm

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enforcement conference %s neld,in the NRC Region IIIJ office on May 25, '

Mg /3 ' 1990. cThe preliminary gfsindings.Kwhich were the; bases for these; apparent M Qi violations,iwere" documented in NRCsInspection Report No. 50'266/90008(DRSS);s-50-301/90008(0RSS), and were transmitted to th'e licensee by letter dated

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May'18,fl990. tThevattendees at this enforcement conference are list d,in y '

Section>l abov ~

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TheNRCRegiosIIIstaffsammarized'theinspe~ction' findings, apparent 4

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o lL y vi.olations of regulatory requirements, and other regulatory concern ? . ,p 3 ' The concerns" discussed by the Region III staff-included.the~ apparent]hig !~ 'i radiation-area entry' control incidents and'the3 inadequate' evaluation of' ,

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Lthe; exposure from the fuel fragment. The primary reason for the , ,

enforcement conference was:to obtain additional information from'the '

311censee regarding1the apparent violations in order to determine-

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g9r Regarding the recurrent high radiation area (HRA) entry control J . incidents,.the licenseerindicated that there have been approximately ,

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Meight such incidents dbring the recent Unit 1 and Unit 2 outage >

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. inspection report; however, the licensee also presented information

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hy;~l which(indicates that'al b ths'. incidents'were salf-identified,Ethe events k (

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c Radiation. Work Permit (RWP) related procedures','there were nVsignificant' + h M,W radiological concerns!during the; entries,: that there-msy have been some" X'd

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4 x 3 " standing RWP" and the "rdfueling specific RWP," and#the targeteaudience- * '

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fof specific-training / instruction _ on HRA entry may not h' ave been iof all those who needed;to kno >

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The following completed / planned correc ive: actions:were outlinedt ' ' [ e,i

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EvaluateEthecontent.[ timing'andaudienceforHRA'barrierandRWPJ related training. Iiviement*recomme.ndations prior to the October f,

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v, oi . EUa.l'uatle potentia'1jardware soluti'ons Lto transieht- high' radiation * '

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Concerningtheinadequate9 evaluation'of-theexposurefromthefuel 4 fragment the licensee's presentation did not deviate;significantly from

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T the event description discussed in Section' 4 of 'the aforementioned

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inspection report,. Theslicensee contended that they had been dev' elopin *4 a.h_ot particle' program'since about April 1986, had identified a need for >

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hot particle training'and had completed initial training and completed '

draft guidelines 'on, hut particles prior to , ,/

However, the licensee did not consider the' hot the April'3,-1989 particle programincident, to.be a pri rity item at;that time., TheyLacknowledged thatz lack of specific- ' ' 1 a'

training, inadequate nrecedures, poor communications,among'the healt . . JJ physics management' personnel, and not clearly deli _neating organizatio'nal U + . Tj

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' responsibilities for the hot particle: program,'all contributed to the ,

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y ' event, _ The following(completed / planned corrective < actions were outline i

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9 Additional theoretical hot. particle training was prov.ided td"HPT ?

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in December 1989,

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l Lead HP, supervisors have,been appointed for outage periods,

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This was presented by the Superintendent - Health Physics: '

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,A' forma 1' mechanism has been= created for rn ponding to raqu'ests for

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Increasei the number of retrieval' tools' and provide training on 'their-

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y'  : Thel,seniorgNRC; representative <acknowl0dgedthe' licensee'spre'sentation ' N.] :

o and' stated:that the. licensee would be' notified in writing of the NRC i

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T' . decision regar; ding enforcement actions based on the Linspection, findings.4 J

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A, Three inspectio apparent These viola.tionsoof' apparent violations NRC requirementsierelidentif,ied'

are described;in, Subsections 4.i(1 durjrigit

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and 5> b.' of Inspection: Report No. . 50-266/90008(DRSS);:50:301/90008(DRSS), (J

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but=anoticeofviolationwasnotissuedwith;that' report
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+ review of'information presented by thel: licensee'at(the Enforcement F 3 'g ,

, Conference. As. stated =innSection 2 above;-the liconsee,did not' contest E

~ the apparent violations,. 'However, . additional information conc ~ern'in'g the ,y l

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. -self-identification, root causes and thorough corrective action was

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sy provided atithe Enforcement Conference'regarding thi violation'for

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failure-to"haveavailabletheapprovedproceduresforminimizingradiatio(' n

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exposure during' collection and handling of highly radioactive particle This caused theiNRC: to reco'nsider and find that since the violation was y self-identifie'd and met all criteria for the exercise of discretion of=

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,j Section .V. G.1 of1 Appendix C to 10 CFR.Part 2, a Nocice of Violation will 1'

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< notibe issued for this -Severity Level IV violation (NRC No. 266/90008-02).

UT  ; A Notice of Violation for the remaining two apparent violations is issued

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Enclosure:

. Licensee Handout at'

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HRC REGION lli -

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ENFORCEMENT CONFERENCE MAY 25,1990

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, WISCONSIN ELECTRIC ATTENDEES q

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  • C. W. Fay . Vice President -' Nuclear Power j
  • J.J.Zach Plant Manager - PBNP  !
  • D. F. Johnson Superintendent - Nuclear Regulation l

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  • R. D. Seizert Superintendent - Regulatory &

Support Services  :

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, VIOLATIONS OF  :

o HIGH RADIATION AREA  :

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L BOUNDARIES

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o HIGH RADIATION AREA BARRIER INCIDENTS SEPTEMBER 6,1989. ENFORCEMENT CONFERENCE

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.. SEVERAL INCIDENTS IN 1988 AND IN 1989 l

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e- SEVERITY LEVEL IV VIOLATION ISSUED-e CORRECTIVE ACTIONS TO MINIMlZE RECURRENCE

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E INSPECTION REPORT 50-266/90008; 50-301/90008

. CITED 3 SUBSEQUENT SELF-IDENTIFIED INCIDENTS; VIOLATION OF HRA ENTRY REQUIREMENTS ,

e CONCERNS

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ADEQUACY OF CORRECTIVE ACTIONS FOR PREVIOUS 1 VIOLATIONS

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PURPOSEFUL DISREGARD FOR HRA BOUNDARIES AND RWP RELATED PROCEDURES REVIEW OF ALL SELF-lDENTIFIED HRA BARRIER VIOLATIONS SINCE PREVIOUS VIOLATIONS e 3 DURING 1989 UNIT 2 OUTAGE o 5 DURING 1990 UNIT 1 OUTAGE

e 3 HARDWARE RELATED (2 IN 1989,1 IN 1990)

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e 5 PERSONNEL RELATED (1 IN 1989,4 IN 1990)'

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l BACKGROUND AVERAGE NUldBER OF CONTROLLED' NE .BWP_a ACCESS- CONTRACTORS 1969 UNIT 2 OUTAG'i 1207 630 '421 1990 UNIT 1 OUTAGE 976 565' 267-I CONCLUSION .

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.* SOUND HP PROGRAM  !

. EVENTS DO NOT DEMONSTRATE A PURPOSEFUL DISREGARD FOR HRA AND RWP RELATED PROCEDURES .1 e ZERO TOLERANCE FOR HRA BOUNDARY AND RWP VIOLATIONS ,

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L 1989 INCIDENTS UNIT 2 OUTAGE'

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09/25/89 ROPE BARRIER DOWN OUTSIDE REGEN HX f

I 10/02/89 -

RIBBON BARRIER DOWN AROUND

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REACTOR CAVITY DRAIN LINE COLLECTION DRUM

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10/12/89 -

WE LIAISON ENGINEER BREAKS

, PLANE OF ROPE BARRIER IN CONTAINMENT -

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i 1990 INCIDENTS UNIT 1 OUTAGE:

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,, .04/17/90; -- AUXILIARY OPERATORS CROSS E ,

REFUELING SPECIFIC HRA BARRIER-s' WHILE ON WATCH - ,

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04/21/90 -

CONTRACTOR' PERSONNEL- BACKS

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UNDER ROPE BARRIER

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05/02/90 -

HP CONTRACTOR AUDITOR CROSSES

, . ROPE HRA BARRIER 'AT CONTAINMENT m ACCESS WITHOUT BEING ON RWP 05/04/9 FLASHING RED LIGHT AT REGENERATIVE HEAT EXCHANGER UNPLUGGED .

05/12/90 -

MAINTENANCE SUPERVISOR ENTERS -l

.a . CONTAINMENT WITHOUT BEING ON RWP '

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b SEPTEMBER 25,1989

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ROPE BARRIER DOWN OUTSIDE REGENERATIVE i HEAT EXCHANGER CUBICLE' l

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CAUSE

  • KNOT BECAME UNTIED l

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  • BARRIER CONSERVATIVELY ESTABLISHED BY l, ' PROCEDURE IMMEDIATELY AFTER SHUTDOWN TO- -
ALLOW CONTAINMENT ACCESS WHILE DETAILED SURVEYS ARE BEING CONDUCTED >
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L SUBSEQUENT DETAILED SURVEY SHOWED THAT AREA WAS NOT A HRA - BARRIER REMOVED f J IMMEDIATE CORRECTIVE ACTION d u

c -DISCOVERED BY MAINTENANCE PERSONNEL AND ,

[; REPORTED TO HP' l L

l - HP IMMEDIATELY REESTABLISHED THE BARRIER ,1 L

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OCTOBER 2,.1989 RIBBON BARRIER DOWN AROUND REACTOR

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CAVITY DRAIN LINE COLLECTION DRUM CAUSE s

  • WElGHT OF SIGN ON THE RIBBON CAUSED THE

. KNOT TO BECOME UNTIED BACKGROUND

- * HP SUPERVISOR RESPONSIBILITY TO MAK l BEGINNING, MID AND END-OF-SHIFT TOURS TO l SURVEY HRA BARRIERS

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  • DURING END-OF-SHIFT TOUR, APPROXIMATELY -

L 0300, THE BARRIER WAS VERIFIED TO:BE i L ESTABLISHED j

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  • ' DURING BEGINNING-OF-SHIFT TOUR,

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APPROXIMATELY 0630, THE BARRIER WAS FOUND TO BE DOWN

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.* BOUNDARY IMMEDIATELY REESTABLISHED BY THE L HP SUPERVISOR UPON DISCOVERY L

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' , APRIL 17,1990 PAB AUXILIARY OPERATORS CROSS REFUELING SPECIFIC HRA BARRIER AT SPENT FUEL POOL-l: l E CAUSE L

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  • CONFUSION RELATED.TO REQUIREMENTS OF- q

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H i: * LOCATION - EL. 66' PAB SOUTH WALKWAY TO SFP BACKGROUND

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  • AUXILIARY OPERATORS ON STANDING RWP
  • HRA ENTRY IS REQUIRED AS PART OF PAB AUXILIARY OPERATORS WATCHL ,
  • INDIVIDUALS HAD RECEIVED HRA BARRIER 4 TRAINING BUT WERE NOT SENSITIZED TO THE REQUIREMENTS OF THE REFUELING SPECIFIC RWP FOR THE UNIT 1 OUTAGE

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-* STATEMENT ON HRA BOUNDARY SIGN " CAUTION, HIGH RADIATION AREA, RWP REQUIRED FOR ENTRY"

  • STATEMENT ON REFUELING SPECIFIC HRA >

BOUNDARY SIGN " CAUTION, HIGH RADIATION AREA, RWP REQUIRED FOR ENTRY, FUEL MOVEMENT IN PROGRESS"

  • HISTORICALLY, WALKWAYS AROUND SFP NOT POSTED. REFUELING SPECIFIC RWP AND HRA BARRIERS BEGAN IN 1988 AS A RESULT OF INCIDENT DURING 1988 UNIT 1 OUTAGE DURING ;

FUEL TRANSFER.

'

l I

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_1r=__1______________ .__.-

_ _ _ .- . . - . _ _ _ __ . . . _ _ . _ _ _ _ _ . . _ . . _ . .

_ 7

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, 7 1 OCTOBER 12,1989

L LIAISON ENGINEER BREAKS VERTICAL PLANE l: OF ROPE BARRIER -)

CAUSE -

,. 1

  • UNDERSTANDING 1

!

.,

  • . JOB FOCUS .

o

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,

BACKGROUND I L +- TEN YEAR REACTOR VESSEL EXAM BY SWRI  :

c

'

WE LIAISON ENGINEER SUPERVISING /- '

COORDINATING

&

'

  • PREPARATIONS FOR CORE BARREL LIFT,

i 9;p INCLUDING ESTABLISHING HRA BARRIERS

"

-jP'

.

LOCATION OF BARRIER

.,

  • CONTAINMENTTOUR TO VERIFY PROGRESS AND i

'

ESTABLISH SHORT TERM SCHEDULE WITH SWRI w '

  • LEANED OVER ROPE BARRIER IMY.EDIATE CORRECTIVE ACTION  !

,

  • HPTECH INFORMED HP SUPERVISOR i J, i
  • HP SUPERVISOR QUESTIONED'AND CLARIFIED

'

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  • LIAISON ENGINER SELF REPORTED INCIDENT TO SUPERINTENDENT OF HP AND PLANT MANAGER

'

!

.

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.

.,, ... *

  • HIGH DOSE RATES INTERMITTFNT AND TRANSIENT-c

!

'

4 * COMPLIED WITH ALL STANDING RWP  !

REQUIREMENTS  !

'

>

  • SAME AS REFUELING SPECIFIC RWP I REQUIREMENT l
  • SIMILAR,TO INCIDENT DURING 1989 UNIT 1

' OUTAGE 1- ,

H IMMEDIATE CORRECTIVE ACTION

.i

OPERATOR ON REFUELING TEAM STOPPED AOs i AND INFORMED THEM OF SPECIFIC RWP !

REQUIREMENT I

  • AOs LEFT AREA AND IMMEDIATELY REPORTED TO HP TECHNICIAN THE PROBLEM AND SUGGESTED THAT CLARIFICATION OF THE POSTING IS NEEDED

!

-

9 u' ~

_ . _ _ . _ . . _ _ _ _ . - _ _ . _ . _ _ _ . . . _ _ _ _ _ _ _ _ _ _ _ . _ .. . _

-

,

. .

. '

APRIL 21,- 1990

[ ,

- CONTRACTOR BACKS UNDER ROPE HRA BOUNDARY ,

ll WHILE REMOVING STEAM GENERATOR SLUDGE '

L, LANCE EQUIPMENT l

CAUSE

, -* DID NOT SEE BARRIER  ;

,

  • JOB FOCUS 1 BACKGROUND

'

STEAM GENERATOR SLUDGE LANCING' COMPLETE.- ,

'

EQUIPMENT BEING REMOVE '

  • DIRECT HP COVERAGE

,

CONTRACTOR BACKS UNDER REACTOR VESSEL HEAD LAYDOWN AREA-ROPE HRA BOUNDARY- <

  • FULL COMPLIANCE WITH RWP REQUIREMENTS l ASSOCIATED WITH SLUDGE LANCING

NOT ON RWP ASSOCIATED WITH ENTRY INTO .i LREACTOR VESSEL HEAD LAYDOWN.HRA ,

-!

CORRECTIVE ACTION

,

CONTRACTOR IMMEDIATELY STOPPED

HP TOOK' APPROPRIATE CORRECTIVE ACTION AT SCENE .

,

.-a

- _

_ -_--_ _ _ _ _ - - - - _ - - - _ _ - _ _ _ _ _ _ - _ - _ - - - - - - - - _ _ - - - - - _ _ - - - - _ - _ - _ _ - - _ - - - -

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MAY 2,1990

'

HP CONTRACTOR AUDITOR CROSSES HRA BARRIER

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, DURING UPPER INTERNALS LIFT CAUSE

'

  1. -* LACK OF FAMILIARITY WITH SITE REQUIREMENTS
  • WITHOUT HP SITE COORDINATOR u< BACKGROUND 1' '

-;

  • FIRST VISIT TO SITE El

'

e GET ON MAY 1,1990- 1

'

  • PLANT TOUR WITH CONTRACTOR HP SITE COORDINATOR ON

,

MORNING OF MAY 2,1990_ -;

p

  • SITE COORDINATOR INFORMED- AUDITOR THAT GENERAL i

[: ENTRY INTO CONTAINMENT DID NOT REQUIRE RWP J

  • IN PREPARATION FOR UPPER INTERNALS LIFT, ACCESS TO CONTAINMENT EL. 66' WAS RESTRICTED BY HRA BOUNDARY AT UPPER ACCESS AT APPROXIMATELY 1100 ON MAY 2,1990
  • AT.1130, AUDITOR CROSSED ROPE HRA BOUNDARY AT-. '

CONTAINMENT ACCESS IMMEDIATE CORRECTIVE ACTION

,

'"

'

  • HP TECHNICIAN COVERING UPPER INTERNALS LIFT STOPPED c AUDITOR AT CONTAINMENT ACCESS AND DIRECTED HIM TO LEAVE AREA

/

  • AUDITORS SITE ACCESS AUTHORIZATION WAS RESCINDED ON MAY 3,1990

!

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_ _ _ _ . . . _ .

'A '

.

,i MAY'4,1990

.

FLASHING RED LIGHT AT REGENERATIVE r - HEAT EXCHANGER CUBICLE FOUND NOT FLASHING CAUSE .

'

'

.

  • - POWER CABLE TO LIGHT UNPLUGGED ,
  • POWER CABLE NOT SECURED TO POWER OUTLET l

BACKGROUND

  • -' CUBICLE DOOR REMOVED-TO ADD SHIELDING.

e PROPER BARRIERS WERE ESTABLISHED WITH -

WARNING LIGH *-

FLASHING RED LIGHT CONFIRMED TO BE OPERATING AT 2320 AT COMPLETION OF A NON-RELATED HP COVERED JOB e * HP TECHNICIAN FOUND LIGHT TO BE UNPLUGGED WHILE ON ROUTINE SURVEILLANCE

  • ROPE BOUNDARY IN PLACE-

. .

1 IMMEDIATE CORRECTIVE ACTION

,

  • HP TECHNICIAN PLUGGED IN AND TIE WRAPPED :

THE POWER CABLE TO THE OUTLET .

l

.. : '-

f, - MAY 12,1990 -

"

MAINTENANCE SUPERVISOR ENTERS CONTAINMENT WITHOUT RWP AUTHORIZATION CAUSE

'

  • LACK OF SPECIFIC COMMUNICATION
  • FIRST TIME THE MAINTENANCE SUPERVISOR HAD.TO BE O ;;

'

RWP TO ENTER CONTAINMENT

,

o BACKGROUND-

,

, ,

  • CONTAINMENT INTEGRITY HAD BEEN ESTABLISHED FOR

'

RECOVERY FROM OUTAGE H

  • PROPERLY POSTED WITH VISUAL AND' AUDIBLE ALARMS IN ,

PLACE

' * MAINTENANCE SUPERVISOR ASKED TWO HP TECHNICIANS IF i HE COULD ACCOMPANY THEM INTO CONTAINMENT

  • HP TECHNICIANS ASSUMED THE MAINTENANCE SUPERVISOR 1

'

WAS ON'THE RWP. HE WAS NO s'

  • THE HP TECHNICIAN' ASSIGNED TO SURVEY THE EL 66' OF CONTAINMENT QUESTIONED WHETHER MAINTENANCE l

SUPERVISOR MET THE REQUIREMENTS FOR CONTAINMENT ENTRY- -

!

!

IMMEDIATE CORRECTIVE ACTION

  • CONFIRMED WITH HP SUPERVISOR, MAINTENANCE ~

SUPERVISOR NOT ON RWP

  • DIRECTED MAINTENANCE SUPERVISOR TO LEAVE CONTAINMENT
  • MAINTENANCE SUPERVISOR LEFT CONTAINMENT IMMEDIATELY AND REPORTED TO HP SUPERVISOR L

. . . - - . . . . . - - - . . . - . . - . - . . . . - - - . _ .

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,  ;

CONCLUSIONS

  • - TOTAL'OF 8 INCIDENTS DURING TWO REFUELIN ;

AND MAINTENANCE OUTAGES i

-

2183 RWPs .

- .

AVERAGE OF APPROXIMATELY 600:

' '

x -

'

CONTROLLED SIDE ACCESS'

AUTHORIZATIONS EACH OUTAGE

-

>

-

'-

HP PROGRAM IS EFFECTIVE i

-

WE AND CONTRACTOR PERSONNEL  :

UNDERSTAND AND:TAKE HP REQUIREMENTS ,

SERIOUSLY AT PBNP l i

WE HAS ZERO TOLERANCE FOR VIOLATIONS

-

-

OF PROCEDURES RELATED TO HRA-BARRIERS AND RWPs-

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[ CORRECTIVE ACTIONS TAKEN'

'e AFTER OCTOBER 2,1989 INCIDENT:-

g-

- ALL RIBBON BARRIERS CHANGED TO ROPE BARRIERS . I k

1v -

. ALL KNOTS RETIED AND' TAPED

'

, , -- - DECEMBER'1969. POLICY RELATED' TO

'

L - RIBBON AND ROPE BARRIERS-7+ .

4 * HRA BARRIER TRAINING EMPHASIS L - *- HRA BARRIER MEMO ISSUED.

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i)e * PRIOR TO 1989 UNIT 2 OUTAGE, OPERATORS-L ASSOCIATED WITH REFUELING OPERATIONS INSTRUCTED ON REFUELING SPECIFIC RWPs ,

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'

a

. .' . ' '

IDENTIFIED WEAKNESSES

. TARGET AUDIENCE OF SPECIFIC TRAINING / INSTRUCTION  ;

' NOT INCLUSIVE OF ALL WHO NEED TO KNOW

.

  • ' TIMING OF HRA BARRIER TRAINING NOT TIED TO OUTAGE ,

s i-4 CONFUSION BETWEEN STANDING RWP REQUIREMENTS AND

'

REFUELING SPECIFIC RWP REQUIREMENTS -

.

-

,

-!

C o

CORRECTIVE ACTIONS

,

. EVALUATE CONTENT, TIMING AND AUDIENCE OF HRA BARRIER AND RWP RELATEDTRAINING. IMPLEMENT

'

.

. RECOMMENDATIONS PRIOR TO 1990 UNIT 2 OUTAGE

-* EVALUATE POTENTIAL' HARDWARE SOLUTIONS TO TRANSIENT HIGH RADIATION AREAS'

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. HOT PARTICLE EVENT i

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I HOT PARTICLE PRESENTATION OUTLINE I * HISTORICAL DEVELOPMENT OF PBNP HOT  :

L PARTICLE PROGRAM L ~* . STATUS OF PROGRAM AS OF APRIL 1989 4 o * BRIEF DISCUSSION OF APRIL 3,1989, EXPOSURE l l EVENT ,

1  ;

E - *- RESPONSE TO EVENT

  • - PROBABLE' ROOT CAUSES .,
  • CONCLUSIONS
  • ' CORRECTIVE ACTIONS d
  • CURRENT STATUS OF PROGRAM

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HISTOR! CAL DEVELOPMENT OF HOT. PARTICLE PROGRAM

-

CALCULATION TECHNI' QUES VALIDATED TO 1 ENSURE ADEQUATE ASSESSMENT I

,l l CAPABILITIES

"

, * TRAINING NEEDS ANALYSIS I

- TNA 86-366 DATED JUNE 5,1986 l

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IDENTIFIED NEED FOR HOT-PARTICLE 4' -TRAINING-u -

" BETA WORKSHOP" TRAINING' COMPLETED DECEMBER 1987, JANUARY 1988

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HISTORICAL DEVELOPMENT (CONT'D)

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  • 'INPO SER 18-87 DATED JULY 7,'198 TNA 87-0708 DATED AUGUST 31,1987:

~

-- PLANT ACCESS TRAINING REVISED JULY 22, t

,

,

1988

-

HP PERSONNEL REQUIRED READING ,

INITIATED OCTOBER 28,1987  !

.- HP FORMAL TRAINING,' SER 18-87 ADDED TO

" BETA WORKSHOP"

- . ADDED SER 18-87 MATERIAL TO HP CONTRACTOR TRAINING MODULE MARCH 10, ,

1988. COMPLETED IN PRE-OUTAGE TRAINING

-

ADDED SER 18-87 MATERIAL TO OPERATIONS-GROUP CONTINUING TRAINING MODUL .

-

TRAINING COMPLETED JULY 28,1988.'

-

HP INITIAL TRAINING REVISED TO INCLUDE

'

SER 18-87 MATERIAL l- * ARP DECEMBER 16,1987

t, *FRP OCTOBER 6,1989

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HISTORICAL DEVELOPMENT (CONT'D)

AUGUST 21,1987

" -

ADDED ADDITIONAL FRISKER STATIONS

-

REVISED PERSONNEL- MONITORING REQUIREMENTS .

,

1 -

INCREASED SURVEILLANCE OF SFP AND SFP - I

.

HANDLING EQUIPMENT- 1 y

-

INSTALLED PCM-1Bs AT EXIT FROM l CONTROLLED ZONE y l D -

INITIATED PROCESS TO PROCURE (g - AUTOMATED LAUNDRY-MONITOR' SYSTEM j 4 i j , -

COMPLETED UPFLOW MODIFICATIONS (

11- .

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PROCURED ULTRASONIC FUEL INSPECTION EQUIPMENT l

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,. HISTORICAL DEVELOPMENT (CONT'D).

} "c '  !* HP GROUP MEETING ON NOVEMBER 29,1968 - . .3 m

L IDENTIFIED NEED FOR ADDITIONAL- HOT PARTICLE -

W,,

TRAINING -

.'

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-

"

. *- .TNA 88-0710. TRAINING SCHEDULED FOR -

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v DECEMBER,1989. .

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HISTORICAL DEVELOPMENT (CONT'D)

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'

-

STEAM GENERATOR WORK PROCEDURES 1 AND STANDING ORDERS ADEQUATELY CONTROLLED STEAM GENERATOR WOR '

HAD BEEN REVISED IN SEPTEMBER 198 DRAFT HOT PARTICLE GUIDELINES UNDER DEVELOPMENT

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HISTORICAL DEVELOPMENT (CONT'D)

  • DEVELOPMENT OF FORMAL HOT PARTICLE PROGRAM i

.)

- PROGRAM USED DURING 1987 AND 1988  !

,

OUTAGES HAD BEEN CONTROLLED BY  :

SPECIAL INSTRUCTIONS AND CHECKLISTS l L - NOVEMBER 1988 - SUPERINTENDENT -

HEALTH PHYSICS ASSIGNS SPECIALIST THE

RESPONSIBILITY FOR DEVELOPMENT OF  ;

FORMAL HOT PARTICLE PROGRAM i

- PROGRAM DEVELOPMENT INCLUDED IN 1989

- OBJECTIVES. MILESTONES ESTABLISHED J

- DECEMBER 1988 WORK ON GUIDELINES r INITIATED b - GulpflLINES COMPLETED AND USED IN ,

DRAFT FORM PRIOR TO UNIT 11989 OUTAGE l

- HEALTH PHYSICS GROUP MEETING HELD ON i< MARCH 30,1989 TO DISCUSS APPLICATION OF DRAFT GUIDELINES  ;

-

.

-

.

_ . . - - _ . _ _ _ _ _ _ . . _ . _ . _ _ . . . _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ , _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ . _ _ _ _ . _

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RESPONSE TO APRIL 3,1989 EVENT j

  • APRIL 4 NUCLEAR SPECIALIST NOTIFIES SUPERINTENDENT - HEALTH PHYSICS VIA MEMO OF APRIL 3 i HOT PARTICL j SUPERINTENDENT- HEALTH 1 PHYSICS RESPONDS WITH 1 QUESTION j

, * APRIL 4 NUCLEAR SPECIALIST RESPONDS i TO QUESTIONS AND PROVIDES ,

'

SECOND MEMO TO SUPERINTENDENT - HEALTH-  :

PHYSICS. ESTIMATED EXTREMITY l DOSE ASSUMED AN EXPOSURE DISTANCE OF 18 lNCHES, 1 SUPERINTENDENT - HEALTH PHYSICS CONCLUDED THAT  !

'

PARTICLE WAS NOT DIRECTLY  !

HANDLED. NUCLEAR SPECIALIST 1'

TO CONTINUE EVALUATION FOLLOWING RECEIPT Ol' .

EMPLOYEES' STATEMEN .* l j

  • MID APRIL INVOLVED HEALTH PHYSICS l

TECHNOLOGIST MADE PERIODIC I INQUIRIES REGARDING l ASSESSMEN !

!

  • LATE APRIL NUCLEAR SPECIALIST COMPLETES )

" UNOFFICIAL ESTIMATE" OF l EXPOSURE AND PROVIDES TO l HEALTH PHYSICS TECHNOLOGIST f'

I

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.L'* _ . _ . . - . . ._,._.-. . _ . . . . _ . _ . ~ . . . _ _ _ _ -_._, .._.. , . . _ . . _ _ . - . _ _ _ . _ _ _ _ _ . . . . _ . . _ . . . . _ _ _ .

. _ . _ . _ _ . _ _ _ _ . _ . . . _ _ . . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ .

i

., -  !

,

i HISTORICAL DEVELOPMENT (CONT'D)  !

!

  • 1989 MBO ACTION PLAN

i - OBJECTIVE; j I

" DEVELOP AND IMPLEMENT A FORMAL i

'

COMPREHENSIVE ' HOT' PARTICLE CONTROL PROGRAM" l l

- ACTION PLAN: COMPREHENSIVE " HOT"

,

]

PARTICLE PROGRAM  ;

l c RESPONSIBILITY: NUCLEAR JPECIALIST j

JFMAMJJASOND l

' REVIEW ANI GUIDELINES X BEGIN INVENTORY SYSTEM FOR .

HOT PARTICLES X DEVELOP HOT PARTICLE ACTION LIMITS X 'I ISSUE UNIT 1 OUTAGE HOT PARTICLE CONTROL GUIDELINES AND ACTION LIMITS X DRAFT PROGRAM PROCEDURES XXXXX l PROVIDE INSTRUCTIONAL SESSIONS l ON PROGRAM PROCEDURES XX

' ISSUE UNIT 2 OUTAGE CONTROL GUIDELINES AND ACTION LIMITS X

,- CONDUCT COMPREHENSIVE HOT

'

PARTICLE TRAINING X

~~_ _- . _ _ - . - . . . _ _ . . _ - _, _ - - _ . . _ . .

_ . _ _ . . _ _ . . _ . . _._____.__._._._.--______.._v__ _ _ .

, . ,

!

. STATUS OF HOT PARTICLE PROGRAM AS OF APRIL 1989

  • DRAFT HOT PARTICLE GUIDELINES, HPGD 25 29, L AVAILABLE MARCH 1989

'

SURVElLLANCE SCHEDULE IMPLEMENTED

+

DOSE CALCULATION METHODOLOGY )

  • i

HOT PARTICLE LOGGING / TRACKING SYSTEM -

.

  • MARCH 30,1989, STAFF MEETING, DISCUSSED I

DRAFT HOT PARTICLE GUIDELINES l

'

'

APPROVED CHEMISTRY PROCEDURE FOR lSOTOPIC ANALYSIS AND QUANTIFICATION

'

" BETA WORKSHOP" TRAINING COMPLETED L

LATE 1987 - EARLY 1988 i *

ACTION / RESPONSE LIMITS ESTABLISHED

t ENHANCED EMPLOYEE FRISKING REQUIREMENTS FOR WORK IN SUSPECT HOT PARTICLE AREAS

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RESPONSE TO APRIL 3,1989 EVENT (CONT'D)  ;

,

  • NOVEMBER 9 HEALTH PHYSICS TECHNOLOGIST  !

, TALKS DIRECTLY TO *

l SUPERINTENDENT HEALTH ,

PHYSICS AND EXPRESSES  ;

CONCERN FOR APRIL 3 EVEN ;

HEALTH PHYSICS TECHNOU) GIST REVEALS THAT HAD DIRECTLY  :

HANDLED THE PARTICL l h

NOVEMBER 10 SUPERINTENDENT - HEALTH  !

F '

PHYSICS REVIEWS PAPERWORK AND ACKNOWLEDGES PROBLE SENIOR MANAGEMENT ADVISE ;

  • NOVEMBER 11 HOT PARTICLE LOCATED AND

'

-14 RETRIEVED FROM WASTE STORAGE DRUM

  • NOVEMBER 15 INITIAL DOSE ASSESSMENT MADE.

'

!

NRC RED PHONE NOTIFICATION IN i l ACCORDANCE WITH 10 CFR 20.403.

l

NOVEMBER 17 REVISED / CONSERVATIVE DOSE ESTIMATE MADE. SECOND RED '

'

'

PHONE NOTIFICATIO <

  • NOVEMBER EVENT REENACTMENTS 21 AND 22 COMPLETE , .
  • DECEMBER 5 NRC'ONSITE EVALUATIO * DECEMBER 8 EVENT INVESTIGATION COMMITTEE COMMISSIONED BY VICE PRESIDENT NUCLEA ,

,,..,,_.,,__,.._y_ , ,_ . . . _ , . .

. _ _ _ _ _ , . _ _ - , . _ _ , , . . , , , . _ . , , , , , _ , . , _ , , _ , , . . . . - , . _ . _

.

. _ . - _ _ _ _ _ _ . _ _ _ _ _ _ _ _ - _ _ . . . _ . _ _ _ _ . _ _ _ _ . . . _ - . _ . _ _ _ _ _ t  :

., '. ,

RESPONSE TO APRIL 3,1989 EVENT (CONT'D)

U

  • DECEMBER 12 EVENT INVESTIGATION COMMITTEE l l

BEGINS WORK.

c

* JANUARY 5 EVENT INVESTIGATION COMMITTEE a' MAKES PRESENTATION TO POINT

.

BEACH MANAGEMENT STAF .

< * JANUARY 31 FINAL DOSE CALCULATION REPORT l COMPLETED AND ISSUE '

)

  • FEBRUARY 1 CORRECTIVE ACTIONS TAKEN AND l- TO APRIL 1 IMPLEMENTED.

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,

O PROBABLE ROOT CAUSES

  • HPTs DID NOT RECElVE ADEQUATE TRAINING IN COLLECTION AND HANDLING OF HOT PARTICLES
  • ESTABLISHED METHODS AND APPROVED

RADIATION CONTROL PROCEDURES FOR COLLECTION AND HANDLING OF HOT PARTICLES WERE NOT AVAILABLE TO HPTs.

.* APPROVED PROCEDURES NOT UTILIZED TO EVALUATE POTENTIAL RADIATION EXPOSURES

  • POOR COMMUNICATIONS AMONG HEALTH PHYSICS MANAGEMENT PERSONNEL

!

ORGANIZATIONAL RESPONSIBILITIES (HOT l PARTICLE PROGRAM) .NOT CLEARLY DELINEATED

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QUALITY ASSURANCE AUDIT (A-P-8915) j

BACKGROUND i

l l * WISCONSIN ELECTRIC NUCLEAR RELATED l

INTERNAL AUDIT OF HEALTH PHYSICS, RADWASTE MANAGEMENT, RADIOLOGICAL j F '

ENVIRONMENTAL MONITORING PROGRAM, L

PROCESS CONTROL PROGRAM, AND THE OFFSITE DOSE CALCULATION M ANUAL; i DECEMBER 18 - 20,1989.

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  • SIX AUDIT FINDING REPORTS ISSUED

- CORRECTIVE ACTION OF  !

i AFR A P 83-13-060 NOT COMPLETED BY-

DUE DATE. (PROCEDURE AND CHECKLIST REVISIONS NOT UPDATED.) '

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CONCLUSIONS EVENT INVESTIGATION COMMITTEE

  • HPTs NOT PROPERLY TRAINED IN HANDLING HOT

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PARTICLES

  • HPTs DO NOT REPORT TO SPECIFIC SUPERVISOR )

DURING OUTAGES I

  • DURING OUTAGES, HP PERSONNEL ARE  !

CONSUMED IN DAILY EVENTS J I

  • NUCLEAR SPECIALIST WAS NOT AWARE OF HIS RESPONSIBILITY FOR HOT PARTICLE PROGRAM i

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  • HEALTH PHYSICIST GETS f00 MANY CALLS AT ,

HOME DURING OUTAGES 'l

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  • NO UNIFORM METHOD FOR RETRIEVING HOT PARTICLE ON A PERSON OR A SURFACE  !

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  • NUCLEAR SPECIALIST SUSPECTED POTENTIAL OVEREXPOSURE. BASED ON LACK OF FEEDBACK, CONDUCTED NO FORMAL EVALUATIO * HPTs DID NOT HAVE A GOOD UNDERSTANDING OF ,

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THE DRAFT HOT PARTICLE GUIDELINES AT TIME OF EVENT

  • HPTs DO NOT RECEIVE FEEDBACK ON EVENTS THAT INVOLVE THEM
  • HP SUPERVISORS HAVE LIMITED KNOWLEDGE OF )

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HPTs TRAINING AND QUALIFICATIONS i

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CORRECTIVE ACTIONS

L * ADDITIONAL THEORETICAL HOT PARTICLE TRAINING WAS t b PROVIDED TO HPTs IN DECEMBER 1989

  • TECHNICAL SPECIALIST HAS BEEN ASSIGNED FORMAL ~

RESPONSIBILITY FOR HOT PARTICLE PROGRAM

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  • GUIDANCE ISSUED TO HP MANAGEMENT PERSONNEL REGARDING OFFSHIFT NOTIFICATION REQUIREMENTS j

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, * LEAD HP SUPERVISORS HAVE BEEN APPOINTED FOR OUTAGE PERIODS

  • THE APRIL 3,1989, EXPOSURE EVENT WAS REVIEWED BY ALL HP PERSONNEL. PRESENTED BY SUPERINTENUENT H ,
  • . A FORMAL MECHANISM HAS BEEN CREATED FOR RESPONDING TO REQUEST FOR DOSE INFORMATION AND CALCULATION ,

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  • NUMBER OF RETRIEVAL TOOLS INCREASED. EMPLOYEES TRAINED ON PROPER US ,
  • USE OF HOT PARTICLE DOCUMENTATION FORM IS FORMALIZED. TIMELY REVIEW OF FORM IS REQUIRE ,

i * RWPs ISSUED FOR WORK IN KNOWN OR POTENTIAL HOT

PARTICLE AREAS CONTAIN SPECIFIC CONTROL AND .

MONITORING REQUIREMENT j i

i * HPTs PROVIDED RULES OF THUMB 1

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L l * HP CONTRACTOR TRAINING MODULE REVISED TO INCLUDE SITE SPECIFIC / PRACTICAL HOT PARTICLE TRAININ PROVIDED TO CONTRACTOR HPs PRIOR TO UNIT 11990 OUTAGE

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l AFR A-P-88-13-60 ,

  • RADIOACTIVE MATERIALS HANDLING MANUAL

- MBO OF GROUP TO UPDAT l

- AFR CLOSED AND DEFERRED TO NEXT AUDI RESULTED IN AFR A-P 15119. (CORRECTIVE

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ACTION DUE DATE AIRll1,1990)

- MANY UPDATED AND ISSUED AS OF MARCH 13,199 i

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- WORD PROCESSING CHANGEOVE REMAINDER TO BE UPDATED AND ISSUED BY '

JULY 1,199 :

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,, f CORRECTIVE ACTIONS (CONT'D)

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  • ALL HOT PARTICLE DOSE CALCULATIONS ARE PERFORMED  !

IN ACCORDANCE WITH APPROPRIATE METHODOLOGY AS 3 REQUIRED BY PROCEDURE

SITE SPECIFIC / PRACTICAL HOT PARTICLE TRAINING WAS  ;

PROVIDED TO ALL WE HP TECHNOLOGISTS IN FEBRUARY,  ;

MARCH 1990 '

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  • AN EVALUATION OF THE CONTENT OF GENERAL EMPLOYEE-  ;

TRAINING (GET) PROGRAM CONTENT REGARDING HOT  ;

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PARTICLES IS IN PROGRESS

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CURRENT STATUS OF HOT PARTICLE PROGRAM

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  • TRAINING

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SITE SPECIFIC / PRACTICAL TRAINING l

- NEW PROCEDURES l

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- INCLUDED BOTH WE AND CONTRACTOR )

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HP TECHNOLOGISTS AND SUPERVISORS SURVEY AND RETRIEVAL TECHNIQUES l l

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  • NEW PROCEDURES
HP 2.15, HP 2.15.1, HP 2.15.2 L
  • HOT PARTICLE RETRIEVAL TOOLS AVAILABLE o * HOT PARTICLE DOCUMENTATION SYSTEM

, * FORMAL LEAD RESPONSIBILITY FOR PROGRAM o  ;

  • FORMAL DOSE CALCULATION METHODOLOGY
  • RULES OF THUMB e
  • PROCEDURES FOR QUANTIFICATION

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QUALITY ASSURANCE AUDIT .

( A-P-89-15)

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GAY 1 8 M J

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i Docket No. 50-266 Docket No. 50-301 EA 90-099

Wisconsin Electric Power Company ,

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ATTN: Mr. C. W. Fay Vice President >

Nuclear Power 231 West Michigan Street - P379 Milwaukee, WI 53201  :

Gentlemen:

This refers to the routine and special safety inspection conducted by Messrs. W. B. Grant and A. W. Markley of this office during the period ,

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April 23 - May 3, 1990, of activities at the Point Beach Nuclear Plan Units 1 & 2, authorized by NRC Operating License No. DPR-24 and No. DPR-27 i and to the discussion of our findings with Mr. James Zach and others of your -

staff.following the' inspectio The enclosed copy of our inspection report identifies areas examined during ,

the inspection. Within these areas, the inspection consisted of a selective examination of procedures and representative records, observations, and interviews with personne During this inspection, certain of your activities appeared to be in violation of NRC requirements. You will be notified by separate correspondence of our decision regarding enforcement actions based on the findings of this inspection. No written response'is required until you are notified of the proposed enforcement action 'In a

REGION 111 Report N /90008(DR55); 50-301/9000S(DR55)

Docket No ; 50-301 License Nos. OPR-24; DPR-27 Licensee: Wisconsin Electric Power Company 231 West Michigan

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Milwaukee, W! $3201 Facility Name: Point Beach Units 1 & 2 Inspection /' Two Rivers, Wisconsin Inspection C c pril 23-26, 1990 and May 3, 1990 Inspector: W. B. Grant C /7 !T C

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te Ins r y wL Approved By: wit 11am Snell,

ief g/c}/fo Radiological Controls and (iate Emergency Preparedness Section l

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Inspection Summary Inspection on April 23-26, 1990 and May 3,1990 (Report No. 50-266/90008(DRSS): !

No. 50-T0179EiD8TDYfS))

Area siTnspected: Routine and special announced inspection of the radiological protection program during a refueling and maintenance outage, including:

(1) hot particle event (IP 93702),(2) organizations 1 and management controls, (3) audits and appraisals, (4) external exposure r,ontrol, (5) control of '

radioactive materials, (6) contamination and surveys, and (7) maintaining occupational exposures ALARA (IP 83729,83750). Also reviewed were several recent incidents involving breaching of high radiation area (HRA) barrier .

corrective actions on previous violations and other identified concerns j (IP 92701, 92702).  !

Results: The review of the April 3,1989, hot particle incident indicated that a regulatory overexposure (pursuant to 10 CFR 20.101) did not occu Apparent viciations of regulatory requirements associated with the hot particle incident and recurrent high radiation area boundary violations were identified (Section 4 and 5, respectively). The appropriate enforcement actions for these apparent violations will be determined and communicated to the licensee by separate correspondence. In addition, one non-cited violation (NCV) was identified in a Technical Specification audi !

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1.- Persons Contacted o

  • J. Anthony, Quality Engineer

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' * J. Develacqua, Superintendent, Health Physics

  • R. Bredvad, Health Physicist W. Doolittle, Health' Physics Specialist E. Epstein,' Health Physics Specialist

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D. Florence, Health Physics Technologist

  • C. Gates, Radwaste Superviso T. Guay, Health Physics Supervisor D. Johnson, Superintendent Nuclear Regulation

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E. Lange, Lead Health Physics Supervisor M. Moseman, Lead Health Physics Specialist P. Scheffel, Health Physics Supervisor

  • R. Seizert, Regulatory Engineer i
  • 'J. Zach, Point Beach Nuclear Plant, Manager t, * C. Vanderniet, Senior Resident inspector J. Gadzala, Resident Inspector The inspectors also interviewed other Licensee and contractor personnel during the course of the inspectio * Denotes those present at the Exit Meeting on April 26, 199 . General i

This inspection was conducted to review various aspects of the licensee's radiation protection program during a refueling and maintenance outage, including: the April 3, 1989 hot particle event, changes since the last inspection, audits and surveillances, exposure control, control of radioactive materials, ALARA, and the licensee's corrective actions regarding previous-violations and identified concerns. During the

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performance of plant tours, no significant access control, posting or procedural adherence problems were identified. HouscLeeping and material l

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conditions were generally good. However, housekeeping was poor in the lower two levels of the primary auxiliary building and the lower level of both facade buildings, u j Licensee Action on Previous Inspection Findings (IP 92701)

{ Closed)0)enItem(266/89022-04;301/89021-04): Establish more stringent teyway entry controls. ~}n response to this concern the licensee has completed the following items:

1.- HP procedure 2,14 has been written and issued. This procedure is a

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step-by-step sign off procedure which is designed to ensure proper authorizations and verification l d

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lb : 1 5 Health Physics Guideline (HPGD) 32 has been issue This guideline provides health physics personnel with instructions regarding expected radiological conditions and appropriate precautions for Leyway entr . A unique padlock is now used to control access to the Leyways. The keys to these padlocks are under direct control of health physics supervision. Entries to the Leyway may only be ' authorized by the Superintendent - Health Physics or the Health Physicis [C,losed) UnresA l led item (266/89031-02: 301/89031-02): Resolve the problems wid the solidification process and discuss with the processing

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vendor t.nd the burial site to arrive at a suitable solution. The licensee has completed the action items associated with the solidification process. Discussions with the processing vendor and the burial site have been hel (Closed) Unresolved item (266/89030-02): Potential overexposure of a health physics technician, lhe licensee has completed their investigation of this event. The licensee's investigation concluded that the technician received a maximum localized dose to the skin of the extremity of 12.4 rem. The inspectors reviewed the licensee's analysis of this eventandtherecommendedcorrectiveactions(SeeSection4), Hot Particle Event (IP 93702)

While performing a survey of the lower reactor cavity on April 3,1989, a health physics technologist handled a small fuel fragment in his left hand. This action-resulted in a significant extremity skin exposur Corrective actions and exposure evaluations performed following the event did not appropriately characterize the event. The significance of the event and the associated exposure consequences were nnt identified until'

the health physics technologist directly communicated his concerns to the Superintendent - Health Physics on November 9,19 On November 15, 1989, the initial dose assessment was reported to the NRC as 75 rem to the skin of the left hand. This estimate was revised and reported as 375 - 400 rem on November 17, 1989. Further refinement of the dose assessment by December 8,1989, indicated a maximum extremity skin dose to one square centimeter of the health physics technologist's lef t hand of approximately 20 re On December 8,1989, the licensee commissioned an Event Investigation Committee composed of individuals who were not associated with Point Beach Nuclear Plant. This committee was chartered to investigate the failure to properly characterize the event in April 1989, to evaluate event precursors, and to recommend corrective actions to prevent a similar event from recurring. On January 31, 1990, the licensee completed the dose assessment and concluded that the health physics technologist received a maximum extremity skin dose of 12.4 rem as a result of his exposure to the fuel fragment, j

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Decause there was a potential for sigr.ificant radiation exposure f rom

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this event, a Radiation Specialist and an accompanytr.g inspector were t dispatched f rom Region 111 to the site to perform tt e initial event follow-up inspection on December 4,19S9. In additien to the licensee's assessment, the NRC engaged Brookhaven National Laboratory to perform an independent dose assessment. The ENL evaluation ressited in_ a calculated maximum exposure of 13 rem utilizing licensee assum;tions for fuel

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fragment composition, activity and exposure scenario (time, distance and

, shielding). The BNL evaluation was completed on March 13, 199 [

' s This inspection was perforced to follew-up on the results of the a'

licensee's investigation committee's report and findings, completion of :

dose assessment activities, and the identification-ard implementation of r corrective actions.

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a, ,ParticleCoQection

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On April 3, 1989, while performing a survey of the reactor cavity, a health physics technologist (HPT) accompanied by a HPT trainee 1 encountered a hot particle located on the floor. The HpT's teletector exhibited a reading of 2-3 rem /hr. The HPT attempted !

to collect this particle by utilizing a piece of tape. The tape 1 was pressed onto the particle by the HPT's left hand. This ,

technique was employed several times until the particle was _

captured. The teletector was used to provide ccnfirmation of l particle collection between attempts and upon ecliection. The tape '

with the adhered particle was then placed in a plastic bag which was then set adjacent to the cavity wall. At this time, the particle had

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been in contact _with the HPT's left hand for'approximately six seconds (as determined through a re-enactment).

The HPT and HPT trainee contin-

their survey cf the lower cavity ;

collecting approximately five he, cicles of significantly .

lower activity. The HPT who collet ~ the initial particle then measured the bag containing that parucle with an ion chamber ,

instrument (Bicron R50-50). The observed dose rate was in excess

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of 50 rem /hr with the window ope The HPT verified this dose rate I with a different ion chamber instrument (Bicron R50-50). The !

observed dose rate this time was also in excess of 50 rem /hr with the window ope Each time these readings were taken, the HPT who captured the hot particle handled the bag containing the particle at the open end of the bag. The plastic bag containing the particle f'

was then tied tn a r:,pe which was suspended fro- the 66' elevation of the containmen The collection of low activity particles with tspe is generally an industry acceptable practice. However, the collection of high

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activity particles by hand held adhesive tape is not an acceptable practice. The inspectors reviewed the training records for the HPTs and the approved radiation control procedures fer hot particle collection and handling methodology. While nuclear industry experiences with hot particles and skin dose assessment methodologies

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were discussed in the training lesson plans, hot particle collection, !

handling and action level instructions topics were not presented to ;

the HPTs. Approved radiation control procedures that provided ,

instructions for hot particle collection, handling and action levels >

were not available to station personne (

b. Management Notification and Review l

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Upon exiting f rom the reactor cavity, the HPT notified a health physics supervisor of the collection of the hot particle. The HP i supervisor called the Health Physicist at home and reported the hot particle. The Health Physicist asked that the applicable surveys be placed on his desk by mornin On Ap'1 4 Ir89, the Health Physicist forwarded the surveys to the Superini.e',deni, - Health Physics and the Nuclear Specialist for revie The Niclear Specialist wrote a report to the Superintendent - Health i Physics that identified dose rates greater than 200 R/hr beta and i

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8 R/hr gamma on contact and 12 R/hr beta and 500 mr/hr gamma at eighteen inches. Th~s report also discussed potential problems in i

performing an analysis using acid digestion, multichannel analysis and recommending a radwaste drum analysis methodology. Included in '

this report was an initial dose assessment of 2 rem skin dose from the reported surveys and handling methods, but no discussion was provided on the collection metho ;

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On April 4, 1989, the Superintendent - Health Physics reviewed this !

report and returned it to the Nuclear Specialist with written t comment These comments requested a determination by the Nuclear Specialist of the need for analysis; agreed that personal statements were needed; questioned the methodology of the initial dose assessment and directed him to ensure that the hot particle guidelines were implemente On April 4, 1989, the Nuclear Specialist revised the report to the Superintendent - Health Physics. This report maintained the previous exposure rate information. The Nuclear Specialist indicated that the need for analysis of the hot particle. and determination of whether a ,

significant beta skin exposure occurred would be based on the >

personal statements provided. In addition, a worst case skin dose

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estimate would be less than two rem from surveys and reported handling ,

methods. This estimate assumed a six-minute exposure at eighteen inches f rom the bag for a skin dose to the extremitie In summary, health physics management was aware that a significant hot particle had been found. The need to obtain additional -

information regarding the potential exposure was recognize Concerns expressed by the Superintendent - Health Physics regarding the initial dose assessment methodology were not addressed. Lastly, dose assessment information which did not have an adequate basis was communicated to the Superintendent - Health Physic } >

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, . Personal Statements by HPis The HPTs who performed the reactor cavity surveys and hot particle '

collections on April 3, 1989, provided their statements regarding these activities on April 5, 198 The HPT who handled the hot particle indicated in his statement that he used tape held in his left hand to capture the particl Upon collection, the HPT indicated that the tape with the particle was immediately placed into a plastic shoe bag and kept out of the u '

work area. This HPT then took a dose rate of the particle with a

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Bicron R50-50 (ion chamber instrument) and tied the bag with the '

particle to a rope suspended from the 66' elevation of the containmen At this point, health physics management personnel were made aware that the HPT had handled the hot particle in his left hand, d. Dose Assessments of April 1989 During the ensuing weeks after the hot particle had been handled by the HPT, the HPT reportedly made periodic inquiries regarding an assessment of exposure that he had received, ibis culminated in an '

" unofficial estimate" prepared by the Nuclear Specialist. In a document titled Extremity Exposure Estimate for Hot Particle Collection, the fiuclear Specialist identified.the methodology utilized and the calculations performed to atsess the HPT's extremity skin dose. This resulted in a " Total Estimated Extremity Dose" of :

530 mrem, t The inspectors reviewed this " unofficial estimate" for technical adequacy and for conformance with approved procedures and established -

methods. The technique utilized differed from the method.specified, but not required, by licensee procedure HP.? 1.6, Estimating Skin &

Internal Dose Rates Due To Skin Contamination, in addition, this assessment did not utilize the dose assessment software that had been used by the licensee to evaluate hot particle / activated component exposures that had occurred previously, as follows:: r Date Software Incident 4 14/89 QAD, BTHIH Split pin fragret found in steam generator afd handled by staff engineers 5 10/87 QAD Calibration source was handled by instrument maintenance l

personnel

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4/21/87 VARSK1H,QAD Hot particles found on two contract HP technicians 6 ,

in addition, the technique specified in CAMP 409, Acid Digestion of Radioactive Solid Sample for Gamma Spectroscopic Analysis, was not utilized to evaluate the nature of the the HPT's exposure. 1his technique had been utilized after the May 12, 1988, incident in which a 39-microcurie fuel particle had been found on a contract HP technician's glov In summary, health physics management was made aware of a potentially significant extremity skin exposure during April 1989. The licensee had. adequate methods available to perform dose assessnents due to hot particle The. licensee failed to perform an adequate evaluation of the exposure received by the HP Event Inve'tigation s Committee Conclusions The Event Investigation Committee identified the following items as the' root and contributing causes of the even (1) HPTs were not properly trained in handling hot particles found ,

on a surface. This includes the proper method of surveying as well as retrieva (2) HPTs do not report to a specific HP supervisor during outage This leads to confusion over specific work direction (3) During outages, HP personnel (Superintendent, Health Physicist, Supervisors and HPTs) are consumed by daily events and have little if any time to look back or plan ahea .(4) The Nuclear Speialist was not aware that he had prime / sole responsibility for the Hot Particle Progra ,

I (5) The Health Physicist gets too many calls at home during an outag (C) There is no uniform method for retrieving a hot particle on either a person or a surfac (7) The Nuclear Specialist suspected the. . was a potential problem with 6n overexposure but based on lack of feedback from the Superintendent - Health Physi s conducted no further formal ,

evaluation of the even (8) HPTs did not have a good understanding of the draft Hot Particle Guidelines during the Spring 1989 outag (9) HPTs do not routinely receive feedback on events that concern .

the (10) HP Supervisors appear to have limited knowledge of individual HPT's and HPT trainee's training and qualifications.

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f. Root Causes The inspectors reviewed the event, interviewed licensee personnel and evaluated documentation. The following delineates the primary l root causes of the hot particle incident of April 3, 198 (1) HPTs did not receive adequate training in the methods to g minimize radiation exposure during the collection and handling '

of hot particles and activated component (2) Established methods and approved radiation control procedures :

for collection and handling of hot particles and activated components, including action levels to minimize radiation exposure were not available to the HPT (3) Approved procedures and methodologies to perform dose assessments were not utilized to evaluate potential radiation g exposure :

(4) Poor communications among health physics nanagement personnel

contributed to the failure to recognize the significance of this even (5) Organizational responsibilities and duties (hot particle program) were not clearly delineated. This contributed to the ,

confusion and communication breakdown g. Event Investigation Committee Recommendations i

The Event Investigation Committee made the following recommendations to prevent recurrence of this event:

(1) Include in the Training Program for HP personnel proper methods for handling hot particles on both people and surfaces. This should include proper methods for detection, retrieval and

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storag (2) formally assign lead responsibility and authority for the Hot -

Particle Progra (3) Limit offshif t calls to the Health Physicist to things requiring immediate action. This includes training HP Su take necessary actions without contacting Health (the)pervisors Physicist.to (4) Implement the following to improve two-way communications in the Health Physics Group:

(a) Define responsibilities of the HP Supervisors during outages to assure HPTs are aware of specific supervisors'

responsibilities such as: Personnel concerns, day-to-day HP activities, specific projects follow up of concerns, et .

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(b) Review the assignment and authority in the Health Physics Group during outages to assure that the Superintendent -

Health Physics and Health Physicist are allowed time to provide "b.g picture" review and oversight of HP activities rather being devoted to " task work."

(c) Review this event prior to the Spring 1990 outage with all

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(5) Develop a method of forn. ally responding to requests for dose calculations. The resulting responses should be independently reviewed and maintained as a record, Licensee Concurrence and Additional Corrective Actions The licensee concurred wfth the Event Investigation Committee conclusions and committed to further enhance the hot particle control program by imolementing the following corrective actions:

(1) increase the number of hot particle retrieval tools at the sit During refueling outage periods, make these retrieval tools available at known hot particle control areas. Train all employees on how to use the retrieval tool '

(2) A hot particle documentation form was implemented prior to the Unit 2 Fall Outage. All HP technologists and trainees should be instructed on the appropriate use of this for Similar to contamination event forms, the hot particle contamination form should receive timely review by the Superintendent - Health Physics or the Health Physicis (3) RWPs which are issued for work in known hot particle areas should have specific hot particle precautions liste (4) HPTs should be provided rules of thumb regarding the correlation between survey instrument readings and potential localized skin dose hazards resulting from direct contact with the particl An understanding of this correlation will allow the HPT to better evaluate the hazards of a hot particle which is measured in the field with a survey mete (5) An evaluation of the health physics contractor training module should be completed prior to the Unit 1 1990 Spring Outage. The program should be updated as appropriate to reflect the revised *

PBNP hot particle control progra (6) Ensure that all hot particle calculations are performed in a:cordance with the specified methodologies described in the PBNP hot particle guideline l

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F (7) HP personnel were provided a two-day hot particle training n,

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program in December of 1989.- Prior to the start of the Unit 2 1990 Spring outage, it was recortnded that the hands-on field i application aspects of this training module be reinforced to

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the HpT Formal instructions on plant specific hot narticle guidelines were also provide '

(8) An evaluation of the acequacy of the hot particle instructional content of the General Employee Training program should be completed. The program should be revised as deemed appropriate.

K Apparent Reculatory Violations

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10 CFR 20.20)(b) requires that each licensee make or cause to b be mads such surveys as (1) may be necessary for the licensee to comply with the regulations in this part, and (2) are

' reasonable under the circumstances to evaluate the extent of

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radiation hazards that may be present. 10 CFR 20.20)(a)

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defi,es a survey as an evaluation of the radiation hazards incident to the production, use, release, disposal or presence of radio ctive materials or other sources of radiation under a T specific set of conditions, i

Contrary to the above, during April 1989, adequate surveys necessary and reasonable to ensure compliance with the

! occupational dose limits of 10 CFR 20.101 were not made after a health physics technologist handled a 142.5 millicurie fuel f ragment on April 3,198 (No. 266/90008-01).

Technical Specification 15.6.11 requires that radiological control procedures shall be written and made available to all station personne Contrary to the above, on April 3, 1939, approved radiological control procedures for minimizing radiation exposure during the collection and handling of highly radioactive particles.and activated components were not made available to station

personnel. (No. 266/900D"-02)

{ Two apparent violations were identifie . High Radiation Area (HRA) Barrier Incidents (IP 9370D In 1988 and 1989, repeated incidents occurred involving HRA barriers in areas where dose rates were between 100 and 1000 millirem per hour. A listing of the incidents and the 1_icensee's corrective action is as '

follows:

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ch , o I Previously Identified HRA Violations and Corre:tive Actions f4 Reference Date Description

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IR 8813/8813 4/20/S8 VHRA warning devices (flashing red

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m light turned of f), Two HRAs not Posted; NOV issued IR 8623/8822 10/19/88 Two HRAs forcibly breached, No NOV-y issued n'

MEMO 10/27/SS Plant Manager informed all workers of importance of barricades, barriers or other warning devices

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IR 8903/E903 10-11/1953 Repeated incider.ts occurred that involved HRA rope barriers

< IR 8922/8921 4/5-15/89 Three times Unit 1 pressurizer HRA barrier not found in place IR 8922/8921 4/11-14/E9 Apparent willful degrading of Unit IR 8928/8927 1 Regen Hx HRA barrier (Twice);

NOV issued IR 8922/8921 4/17/89 Three operators were observed violating a posteo "HRA, RWP Required, No entry during Fuel Movement;" NOV issued

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A *$ verity Level IV violation was issue The licensee's corrective actions included the following:

(1) Training sessions for all plant personnel regarding the HRA entry control incidents, including discussions of applicable regulations and Technical Specifications, summary of events, consequences of inappropriate worker actions, management intolerance of such worker behavior and each worker's responsibilities and obligations. This was conducted by the Superintendent - Health Physic (2) A video tape training session was to be presented to all contractor employees as a part of General Employee Training for

.the Fall outage. Contractors already onsite would be required to view the video tape.

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-(3)^ Mnced training on radiation barriers was to be presented to-contractor health physics- technicians prior to the fall outage.

, (4)? A memorandum was to be issued to all plant personnel reinforcing Technical Specification requirements and health physics procedure conformanc (5) RWPs will be written to provide specific instructions regarding boundary control responsibilities.

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(6) Better operator aids / instructions will be placed on barriers and postings regarding restrictions and responsibilitie (7) Continuing efforts will be made to upgrade HRA barriers,

including replacing ropes with swinging gates where possibl (8) Continuing efforts will be made to eliminate the need for HRA

' barriers, including additional shielding of the Unit 1 Regenerative Heat Exchanger Cubicl (9) The refueling barrier procedure has'been revised for clarity and a training needs analy:,is has been-issued to evaluate training needs for operations personnel, Recent High Radiation Area Violations-Despite the licensee's attempts to institute effective corrective action to prevent recurrence of the 1988/1989 HRA barrier violations, the licensee has identified the following violations:

On October .12,1989, a Milwaukee based individual was observe *._ violating a posted "High Radiation Arsa, RWP Required for Entry" boundary at the north end of the Unit 2 reactor cavity on the 66'

elevation in containment. The individual was not signed onto an

RW On April 17, 1990, two operatars on rounds were observed crossing a

"Hikn Radiation Area, RWP Req 0 ired - Fuel Movement In Progress."

One of these operators was a licensed operator who was performing feiliary Operator duties. The Operators were on a Standing RWP (, hat authorized operations personnel access to the auxiliary, fuel and facade buildings for routine operator rounds. The Standing RWP procedure specifically prohibits access te areas whose radiation

< 1evels are affected by the transfer of spent fuel assemblies during refueling evolutions. Spent fuel transfers were in progres r On May 2,1990, a health physics contract auditor was observed violating a HRA boundary at the entrance to the Unit I containmen ,

The auditor had been assigned to audit HP operations in containmen ...

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The HRA had recently been established in this area because dose rates were between 100 and 1000 millirem per hour due to the lif ting of i the reactor upper internals.. This individual had received General Employee Training, a guided tour of the primary auxiliary building and had been instructed in the access requirements for~ containmen These three incidents are apperent violations of High Radiation Area entry requirements specified by Procedures HP 2.5 and HP 2.5.1 and are representative of violations that.could reasonably be expected to have been prevented by the. licensee's corrective action for the

_previousviolations(No. 266/90008-03;301/90008-03).

One' apparent violation with three examples was identifie . Organizational and Managemant Controls (1 83750)

The inspectors reviewed the licensee's organization and management controls for the radiatlon prctection program, including: organizational structure, staffing, effectiveness of procedures and other management _

techniques nsed to implement the program and experience concerning i self-identification and correction of program implementation weaknesse Early in 1990, .a new Superintendent - Health Physics was appointe A transition period of approximately three months was utilized to allow contineCy between the two individuals. The replacement HP Superintendent u assumed full responsibilities. The transition

. process between the HP Superintendents apparently went smoothl The Nuclear Specialists' training and qualifications were reviewe Each of the nuclear specialists appears to be well qualified and to have a suitable acader.ic background. Current plans include the addition of 4-5 HPTs to the health physics staff to support radwaste activitic , External Exposure Contro'1 and Personal Dosimetry (IP 83750)

The inspectors reviewed the licensee's external exposure control and-personal dosimetry programs, including: changes in facilities; equipment, personnel, and procedures; adequacy of the. dosimetry program to meet routine needs; required records, reports, and notifications; effectiveness of management techniques used to implement these programs; and experience concerning self-identification and correction of program implementation weaknesse No exposures greater than 10 CFR 20.10: limits were note No individual exceeded the licensee's administrative quarterly whole body limit of 2500. mre The licensee has been evaluating an electronic dosimetry system for use 5 l' at the plant. Currently, they are evaluating methods to interface this l' system with the installed exposure records syste l L

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No violation's or; deviations'were identified.- Control of R6dioactive Materials and Contaminatier. (IP 83750)

The inspectors reviewed the licensee's program.for control?of-radioactive materials and contamination, including: adequacy of supply;' maintenance, and calibration of contamination, survey, and monitoring equipment; effectiveness of survey methods, practices, equiptent=, and procedures;-

adequacy of control of radioactive and contaminattd materials.

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During-tours-of the Radiologically Controlled Area (RCA),-the inspectors observed: performance of contamination surveys; work being performed under radistion work permits; protective clothing use, handling, and

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cleaning; posting and labelling; frisking; tool and equipment handling-

, and storage; and housekeepin RCA housekeeping was generally good with ,

the exception the lower levels of the auxiliary building and the lower '

level of the facade buildings. The inspectors reviewed contamination control procedures for adequacy and survey records for procedural 3 complianc No problems were note The licensee has_ purchased and is using a state of the art. laundry l monitor. Consideration is also being given to the use of wet wash versus dry cleaning of protective clothing. A decision on the most effective i; method is expected in the near futur l No violations or deviations were identifie i 1 Audits and Surveillances (Ip 837501 l i

'The inspectors reviewed the results of Quality Assurance audits and I surveillances conducted by the licensee since the last inspectio Also reviewed were the extent and thoroughness of the audits and' .

surveillances, i The December 1989 quality assurance audit of the radiation protection, '

radwaste, ' radiological environmental monitoring (REMP), process control programs and the Offsite Dose Calculation Manual (03CM) was reviewe The depth and level of evaluation was good. The findings and responses-were reviewed with the following items note ! Technical Specifications r The audit of the ODCM which was required to be performed by July 1989 was not performed until December 198 The audit of the REMP which was required to be performed by January 1989, was not performed until December 198 l

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y The;11censee's actions af ter identification of the audit finding-were

' timely. = Corrective actions have been completed which should prevent

~ future occurrences. Consequently, pursuant to Sections V.G.I. of (Appendix C to;10 CFR Part 2), a llotice of Violation will not be issued for this Severity Level IV violation (11CV 110, 266/90008-04; ~;

301/90008-04). i Corrective Action Implementation l

The corrective action designated for closure of AFR A-P-88-13-060 had not been completed by the committed due date of April 14, 198 The corrective actions identified included procedure and checklis '

revisions for radwaste shipping activitie The audit response indicated a new commitment due date of April 1, 1990, for the

> procedure _and checklist revision As of April 26, 1990, the inspectors determined that the procedure and checklist revisions have yet to be approved and implemente CFR 50 Appendix B, Criterion XVI requires that measures shall be established to assure that conditions adverse to quality such as failures, deficiencies, deviations and nonconformances are promptly identified and correcte This is another example of a violation for which an enforcement

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action has already been proposed (References: EA 89-254, Dated April 17, 1990, inspection Reports fio. 50-266/89033; lio.50-301/89033(DRP)andNo. 50-266/89032;fio.50-301/89'?2(DRP)).

Ito surveillances had been performed since the last inspection.

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will not be issue ~

p 10. Maintaining Occupational Exposures ALARA (.? 83750) -

o The inspector reviewed the licensee's program for maintaining occupational N exposures ALARA, including: ALARA group staffing and qualification; changes in ALARA policy.and procedures, and their implementation; ALARA

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?' considerations for planned, maintenance and refueling outages; worker I awareness and involvement in the ALARA program; establishment of goals and l L

'" objectives, and effectiveness in meeting them. Also reviewed management l

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L ' techniques, program experience and correction of self identified program weaknesses.

1 The total station dose for 1990 was approximately 91 person-rem of which i 1 1 about 75 person-rem was attributed to the ongoing Unit I refueling and l maintenance outage. The licensee's 1989 total dose of 474 person - rem l

! indicates no significant change from previous years. This l undergoes two refueling and maintenance outages each fuel 12 month year (plant no cycles) . Total exposure for the previous six years is listed as follows:

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. _Ye a r ' Persen-R3 Femarts 19S4 1737.155 Includes 245.650 rem for Unit 1 SGRP 1985' 444.050 1986 375.480-1987 532.010 1988 387.255 1989 474.390-

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No violations or deviations were identifie I 11. Exit Interview (IP 30703) ,

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The inspectors met with license representatives-(denoted in Section 1)

following the inspection on April 26, 1990,- to discuss the scope and-findings,of the inspection, including the apparent violations (Sections 4

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and 5).

The inspectors also discussed the likely informational content of the inspection report with regard to documents or processes reviewed by-the

, inspectors during-the inspection. Licensee representatives did not identify any such documents or processes as proprietar ,

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