IR 05000289/1988012

Insp Repts 50-289/88-12 & 50-320/88-09 on 880531-0603. Violations Noted.Major Areas Inspected:Organization,Mgt Controls,Qualifications,Training,Surveys,Posting,Internal Exposure Controls & External Exposure Controls

ML20151B047
Person / Time
Site:	Three Mile Island
Issue date:	07/07/1988
From:	Gresick J, Loesch R, Shanbaky M, Sherbini S NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:
Shared Package
ML20151B041	List: IR 05000289/1988012 ML20151B039 ML20151B043
References
50-289-88-12, 50-320-88-09, NUDOCS 8807200216
Download: ML20151B047 (11)

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U. S. NUCLEAR REGULATORY COMMISSION

REGION I

Report N /88-12 and 50-320/88-09 Docket N and 50-320 License N DPR-16 and DPR-73 Licensee: GPU Nuclear Corporation P. O. Box 480 Middletown, Pennsylvania 17057 l Facility Name: Three Mile Island Units 1 & 2 Inspection At: Middletown, Pennsylvania Inspection Conducted: May 31 - June 3, 1988 Inspectors: , (14- C M4/&8

 /R. Loesch, Radiation Specialist     date
 * Facilities Radiation Protection Section i

Cd 6//F/ty J./presick, Rad 1ation Specialist date Facilities Radiation Protection Section f %L C- 8lI? /SS' 5. Sherbini, Senior Radiation Specialist date Facilities Radiation Protection Section Approved by: M. . M. M. Shanbaky, C te , acK ities 7/7/[[

        ' date Radiation Protection Section
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Inspection Sumary: Inspection on May 31 - June 3, 1988 (Report N /88-12/50-320/88-09).

Areas Inspected: Organization, management controls, qualifications, training, surveys, posting, internal exposure controls external exposure controls, instrumentcalibration,contaminationcontrolandthehotparticleprogra , Results: Two violations were identified: failure to perform a survey section 2.1) and failure to follow procedures (details in section 2.2)(details in

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DETAILS 1.0 Personnel Contacted Licensee Personnel

 * H. Behling, Manager, Radiological Health, TMI-I J. Bevelacqua, Manager, Safety Review Grou
 * A. Bhattacharyya, Nuclear Engineer, PA DER /p BRP
 * J. Byrne, Manager, TMI-2 Licensing
 * L. Edwards, 0QA Monitor, GPUN G. Frank Supervisor Instrument Calibration Facility M.GreenId
 *G.Kuehn,ge,DefuelingSupportManager Radiological Controls Director, THI-l
 * D. Moyer, GET
 * A. Paynter, Lead GRCS, THI-2 R. Perry, Dosimetrist
 * C. Pollard, Radiological Assessor, THI
 * W. Potts Site Operations Director, TMI-2
 * E. Schrull, Licensing TMI-2
 * R. Shaw, Radiological, Engineering manager, THI-1 Director, THI-2
 * Standerfer, Manager, Radiological Engineering, THI-2 J. Tarpinian, Radiological Controls Director, THI-2
 ** D. Turner, Tuttle, Manager, Radiological Field Operations, THI-2
 * R. Zechman, Manager, Technical Training, GPUN 1.2 NRC Personnel
 * R. Conte, Ser.ior Resident Inspector
 * D. Johnson, Resident Inspector T. Mosisk, Resident Inspector A. Sidpara, Resident Inspector 2.0 Recent Incidents of Radiological Significance 2.1 Cutting in the Block Wall in Unit-2 Containment This incident occurred on Monday, April 4, 1988. A robot was being used in the reactor building basement, 281' elevation. The robot was to cut holes in the block wall on the north side of the building. The holes were part of the reactor building basement blockwall leaching project. As part of this pr ject, holes are to be made in the block wall and liquid is to be in ected into the wall to leach the radioactive contaminants out of it. The

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4 robot operator was operating the robot remotely from a control room in the auxiliary building using a television camer Cutting started at about 11:00 in the morning. The robot operator soon found that he was not able to observe the cutting operation on the TV camera because the water used to spray the cutting wheel was splashing onto the camera lens. He therefore alternately turned the water off for short periods of time and then on again. This allowed him to observe the cutting in progres Soon after cutting started, the AMS-3 air monitor in the "C cube" alarme The C cube is an ante room outside the containment air lock at the 305' elevatio Thethe area notified radiological commandcontrols technician center adiacent (C cube area, and theRCT) on duty at the to the RadCon Coordinator at the Coordinat; ion Center, of the alarm. It was then realized that the cutting operation in the basement had starte Investic ation later revealed that the RadCon Coordinator had not been notifieli prior to start of the cutting operation. Cutting was then halted and evacuation of some personnel from the reactor building was started. It was decided not to evacuate everybody because the remaining people were h protection factor. However using because respirators with a increase of the continued sufficiently hikoactive materials in the building of rad air all personnel were eventually evacuated. The AMS-3 in the reactor building exhaust train alarmed at about 11:20. The air activity then began to decrease until at about 14:00 the concentration had reached a point at which normal activities in the reactor building were resume As a result of this incident, three workers were found to have some internal contamination. These workers were in the area of the air lock and the C cube at the time of the incident. Upon whole body counting, the highest lung activity was found to be approximately 180 nC1. This corresponds to an intake of about 12 MPC-hours. The air activity in the area of the C cube is estimated to have reached about 2E-8 uti/cc. The radioisotopes were mainly Cs-137, Co-60, and Sr-9 The licensee held a critique on April 5,1988. During this meeting, it was concluded that the root cause of the incident was poor communications between the robot operator and members of the radiological controls department. The licensee decided to take steps to improve communications as well as to improve the notification system prior to job start The NRC inspector reviewed the licensee's documentation of the incident and concured with the licensee that improvements in communications and job start notifications were needed. However, the events indicated that there were other areas of concern beyond those identified by the licensee. The inspector noted the following:

- The block wall cutting job was performed using Unit Work Instruction (UWI) D-631, "Reactor Building Basement Blochtall le3ching" This UWI
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i specifies that the holes in the block wall are to be punched. Contrary to this instruction, the holes were being cut with a grinding wheel. There was i no evaluation to consider the effects of using this method of cutting on j airborne activity in the reactor building. The concrete was known to be highly contaminated. The inspector stated that the use of cutting tools on the highly contaminated block wall created a substantial potential for generating airborne radioactivity. The airborne dust problem was aggravated by the fact that the water spray on the cutting wheel was stopped during cutting to improve visibility on the TV camera monitor. The inspector stated that failure to evaluate the radiological hazards associated with the use of the cutting tool was an apparent violation of 10 CFR 20.201(b).

(50-320/88-09-01).

- The ALARA review in effect for that iob (ARN 880034 was generated for hole punching in the block wall. Chang;ing the mode of) operation to cutting with a grinding wheel, and sto) ping the water during cutting invalidated the review and required that t1e engineer in charge of the review re-examine it to determine if additional precautions were necessar Radiological Controls Field Operations (RCF0) had instructed the robot operator to contact the Radiological Engineer who generated the ALARA review prior to job start to discuss the proposed method of cutting the holes. RCF0 told the operator that the proposed method of cutting may change the radiological conditions from those anticipated for punching the holes as discussed in the ALARA review. However the robot operator was not able to contact the engineer by the scheduled time to start cutting, and so he went ahead with the job without the engineer's consen The robot operator was required to notify radiological controls prior to start of the operation. However, radiological controls did not know about the work until the air monitors alarmed. The operator apparently did notify the reactor building consand center; he did not realize, however, that this notification did not automatically notify radiological controls. This suggests a poor notification system and inadequate training of personne The licensee's critique focused on two items as the root causes for the incident: poor job planning and communications, and higher than anticipated airborne radioactivity as a result of grinding. A review of the above data indicated that the critique was less than adequate. It did not address the important lapses in the proper procedure to perform jobs on site. These lapses included: change in job scope that was contrary to the UWI and invalidated the ALARA raview; failure to notify the cognizant radiological engineer of the change; and failure to notify radiological controls prior to starting the job. The critique's conclusion that the incident was caused by higher than anticipated airborne radioactivity was misleading and inappropriate since it is not a root cause; rather it is the result of a series of failures that are themselves the root causes of the incident. The critique was conducted by the field operations supervisor who was in charge of the cutting operation at the time of the incident. This practice was poor because it may cause a bias in the analysis of causes and may produce inappropriate conclusions, as it did in this instance. This weakness in identifying root causes of incidents during critiques had been identified ! i

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in previous NRC inspections, and will be reviewed during future inspection Procedure 9200-ADM-4010.02, "ALARA Review Procedure", requires that an ALARA review be prepared for jobs such as the block wall drilling and leaching operations. An ALARA review is based on the details of the process supplied by the requestor to the radiological engineer who 3repares the review. In this case, the details of job performance were clanged after the > review was prepared, and the job was performed in the modified fashion I without amending the review, in effect, therefore, the grinding operation described above was performed without a valid ALARA review. This could have contributed to the April 4, 1988 airborne inciden l 2.2 Worker Falls Into The Reactor Vessel This incident occurred on May 23, 1988, at about 13:00. The worker who fell into the reactor vessel is an experienced boilermaker. He was working on the defueling platform at the time of the incident. The defueling platform is covered by shielded, removable sections, called "plugs" that may be individually removed to allow access to the vessel. A central section of the platform is normally without plugs. This is known as the T-slot and is surrounded by a guard rail with removable chain sections. The worker was engaged in installing supports for underwater plasma arc equipment. He was on RWP #017240, and the work was being performed in accordance with Unit Work Instruction (UWI) #4730-3255-88-T-0100. The UWI referenced procedure S0P 4730-3255-88 R67 Installation of the support structure required that the openin l T-slot be extended at one end by removing a plug at that end31ug (g of

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I The guard chain at that end was also removed. At the time of t1e incide)nt, the work group had finished installing one section of the support structure and were waiting to have the platform rotated in order to complete the installation. During that waiting period the worker in question, in an unrelated activity, and with the approval of the task supervisor, removed a long handling tool from the reactor vessel and was in the process of placing it on a tool rack adjacent to the defueling platform. The rack is located at the end of the open, extended section of the T-slot. The worker was attached to a safety line at that time, but found that he could not manipulate the tool adequately with the line attached. He therefere detached the line and proceeded to put the tool in the rack. As he was doing this, he stepped back and fell through the opening at the open plug location. He did not fall all the way into the water because he managed to j hold onto a ledge in the vessel located above water level. As a result, he ! was immersed only up to his knees. He was then rescued by his fellow workers and his protective clothing was removed (he was in protective clothing and was wearin . Contamination was found on his legs,and g aan powered air purifying initial survey respirator)ing instrument read of the

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contamination showed 5 mrad /hr The worker was estimated to have been in - thc water in the reactor vessel for approximately 3 minute The licensee performed a dose assessment following the incident and assigned the worker an extremity dose of 317 mrem. This was based on an estimate of the gamma exposure from the fuel in the pool plus beta exposure arising from the contamination. The gamma estimate was based on an underwater survey of the pool that showed a dose rate of 300 mrem /hr at 2 to 3 feet below the surface of the water and 5 R canister. The licensee estimates that the worker s foot was /'hratat least 1 foot 6.7 from a fue feet from the nearest canister at the location of the fall, and that the dose from this source would have been negligible. The skin dose assessment was based on contamination surveys and an analysis of the isotopic contents of the vessel water. The worker's TLD on the right thigh showed 49 irem, but this reading included the dose from three previous entries. The self-reading dosimeters for the entry showed a highest reading of 10 mre A review of the circumstances of the incident shows that there was one procedural violation. The procedure in effect at the time of the incident SOP 4730-3255-88-R670 states,insection4.2.11,that"Allpersonnelshuil be tied off when workin adjacent to any unguarded openin in the SWP (Shielded Work Platform ". At the time of the incident, p ug #43 was open and there was no guard hain around that opening. It was herefore a procedural violation to remove the safety line in order to allow manipulation of the tool (50-320/88-09-02).

The critique that was held to analyze the incident did not consider any procedural violations but concentrated on providing a temporary plug for future use and on training personnel on rescue of operations for future falls in the vessel. This weakness in arriving at root causes of incidents and not considering the problem of procedural violations is a recurring problem at TMI-1 and THI-2 (see paragraph 2 of this report). This area will be reviewed during future inspection .0 Organization And Management Controls The staff of the Unit-2 Radiological Controls de generally well qualified both by experience and, in manypartment cases by were found to be formal educationandtraining.Manyofthestaffwerefoundtobequalifiedwell beyond the minimum requirements of their positions. Discussions with members of the organization indicated that most of the staff were technically competent and were aware of their responsibilities in the organization. The radiological controls program appeared to be well managed and many sections of the program were found to be well organized and well run. However, some weaknesses were identified in this are . - - . - _ . . - - - - _ - .- - - - . . . - -. .

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o There is insufficiently forceful insistence by the licensee that proper rocedures and work practices be adhered to at all times. The incidents escribed in section 2 of this report are examples of procedure and work practice violations. A review of the incident event reports also reveals many examples of this tendency. In many of these incidents, the workers did not follow proper procedures, or proper work practices, or changed the work scope without proper authorization and without adequate knowledge of the systems and radiole gical hazards involved. The corrective action in almost all these cases was to council or discipline the workers involved. There is no evidence, hoever, that there has been a licensee effort to address the problem as a sit.e problem and to take appropriate steps to correct it. An example of less than forceful licensee control is the repeated instances of expired survey postings. NRC inspectors have frequently observed area survey postings that were not current. In most such cases, it was later found that the surveys had been performed but had not been posted. The concern over the frequency of events involving procedural violations and poor work practices has been expressed in the licensee's internal report The licensee stated that they intend to take action to correct this situatio The critiques that are held following some of the incidents tend in many cases to be superficial and often fail to identify the root causes. The resulting corrective actions in such cases are generally weak and narrowly focused on specific aspects of the incident. This problem has been previously identified as a weakness in connection with similar situations in Unit- Licensee response to known problems or deficiencies is sometimes inadequate. As an example, many of the incidents reviewed in the event report files were caused by poor practices in handling containments dest ned to confine highly contaminated items or systems. The licensee's anal sis of these events concluded that some form of training on cont inmont systems analogous to that used in Unit-1 was advisabl However, nothing was done in that regard. The licensee stated that this training is offered as part of the c However, since many of the licensee'yclics workers training for site are transient personne contractors, they were not enrolled in this cyclic training. The licensee stated that they will review the situation and implement an appropriate solution to this proble .0 Internal Exposure Control The licensee had established an Internal Exposure Control Program that included: respiratory protection, bioassay air sampling and engineering , controls.Amodernfacilityhadbeenestablishedforthecleaning, l maintenance and inspection of respiratory protection equipment. Suitable

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air samples were being collected and analyzed to support the respiratory protection progra Within the scope of this review, the following were noted:

- All individuals entering Unit 2 containment were issued breathing zone air samplers (BZAs).

- Review of bioassay data indicated no significant intakes by personne Respirator issue was "self serve" rather than controlled issu Although the inspector noted no indications of unqualified personnel wearing respirators, the potential exists for unauthorized use. The licensee stated that alternative methods for controlling issue were being evaluate During review of the Incident Event Reports an internal contamination calculation performed by the licensee was also reviewed by the inspecto The results of the intake calculations performed by the inspector showed a much higher value for the guantity of activity inhaled than that calculated by the licensee. The calculations were based on whole body counter dat Discussions with the licensee revealed disagreements between the inspector and the licensee on questions regarding some of the assumptions made by the licensee. These assumptions involved the appropriate retention functions to use, the solubility of the inhaled activity and the fractional distribution of activity in the body following inhalation. These questions could not be resolved within the time available during this inspectio This matter will therefore be reviewed during a future inspection (50-320/88-09-03).

4.0 External Exposure Controls In-field implementation of external exposure controls was acceptabl Radiation and hich radiation areas were properly controlled and poste Dosimetry use anc; placement, and use of multiple dosimetry, appeared well controlle The inspector reviewed the licensee's most recent dosimetry performance test results for NVLAP accreditation. The performance of the licensee's dosimetry in these tests was found to be acceptabl Administrative controls were established for detection and assessment of hot particles in the form of Standing Orders. These documents had been issued by the Radiation Protection Manager, and carried the weight of approved plant procedures. Discussions with selected HP technicians indicated that the proper level of awareness existed within the

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Radiological Field Operations staff regarding survey requirements and exposure assessmen The licensee currently uses a standard acceptable method for assessin skin dose from generalized skin contamlnations and from hot particles.g The method is based on dose rate conversion factors for skin contamination published in the health physics literature (Kocher & Eckerman published in the Health Physics Journal). The licensee stated that they have developed their own skin dose assessment methods and that they intend to use these metheds in future skin dose assessments. The inspector stated that the new methods will be reviewed during a future inspectio .0 Control of Radioactive Materials and Contamination, Surveys and Monitoring The licensee's program for the control of cadioactive materials and contamination, surveys and monitoring was eviewed with respect to the applicable regulatory requirements and licanse cono,tion The licensee had established the appropri<.te con *,rols for minimizing the spread of contamination through rigorous prot Ntive clothing requirements, providing attendants to assist in the pr )per dress-out and removal of the clothing and appropriate posting of con m Inated areas, radiation areas, highradiationareas,andradioactivematerials. Surveys appeared timely and thoroug .0 Training The licensee's program for training radiation workers and Health Physics technicians was reviewed with respect to criteria contained in the applicable regulatory requirements and license condition Inspector review of the General Employee Training and Radiation Worker Training programs indicated that the pro ram adequately emphasized the appropriate regulatory requirements and lant radiation protection program requirements. However, there appeared t be some deficiencies in workers' understanding of the use of radiological containment devices and the use of portable ventilation, as evidenced by a review of several licensee's internal event reports. The adequacy of the licensee's program for training radiation workers on the use of these devices will be reviewed in a future inspectio The inspector reviewed the licensee's program for the training of Health Physics technicians. A thorough and comprehensive program was in ) lace for initial training and requalification. However, there appeared to se no

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4 system in place for assuring that certain periodic training on current - ! industry events / problems was attended by all technicians. For example, the licensee's training for periodic retraining a newly (Hot Particle Control and Hot Particlecyclic training) provided instituted Exposure Assessment program during June and July, 1987. A review of records of this training indicated that at least seven technicians at Unit 2 did not attend this trainin The inspector brought this to the licensee's attention. The licensee representative stated that he was unaware that these individuals had nat attended the training,.and that he ' would look into the matter further. .However, the licensee stated that 1 there were other mechanisms, such as required reading sign-off lists, for The ins disseminating important information to the technicians. stated that this area would b 7.0 Qualifications ' The inspector reviewed the qualifications of the radiation protection staff and found that the licensee was qualifying contractor radiological control ' technicians in a manner consistent with procedure requirements. However during a review of the staff position descriptions, the inspector noted, - that minimum qualifications ()osition specifications) were not specified for positions other than the Radiological Controls Director. The licensee stated that a revision and consolidation of position descriptions was ongoing at the corporate level, and that these position descriptions were t available for review. These position descriptions will therefore be reviewed during a future inspection.

' i' 8.0 Exit Meeting The inspector met with licensee representatives at the conclusion of the inspection on June 3, 1988. The inspector summarized the purpose of the , inspection and the inspection finding r s , ) l I

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