IR 05000289/1989015
| ML20247E834 | |
| Person / Time | |
|---|---|
| Site: | Crane  |
| Issue date: | 09/05/1989 |
| From: | Pasciak W, Sherbini S NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML20247E826 | List: |
| References | |
| 50-289-89-15, 50-320-89-06, 50-320-89-6, NUDOCS 8909180014 | |
| Download: ML20247E834 (12) | |
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U. S. NUCEAR REGUIATORY OWMISSICH
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REGION I
Report No.-
50-289/89-15 and 50-320/89-06 s
Docket No.: 50-289 and 50-320 x
. License No. = DPR-16 and DPR-73.
. Licensee:? GRJ Nuclear Corporation P. O. Box 480 Middletown, Pennsylvania 17057-Facility Name: Three Mile Island Units 1 & 2
. L'spection At:L Middletown, Pennsylvania Inspection' Conducted: July 24 - 28, 1989 Inspector:
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Ik S. Sherbini, Senior Radiation Specialist date
' Facilities Radiation Protection Section Apprtwed by:
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C W. Pasciak, Chief, Facilities Radiation pat /
Protection Section
' Inspection Summary: Inspection on July 24-28, 1989 (Report No. 50-289/89-15 and 50-320/89-06)
Areas Inspected: The inspection was limited to a review of the organization, staffing, and hot particle control program at the Unit 2 reactor..Also reviewed were the events connected with a suspected intake of radioactive material.
Results: Within the scope of this inspection, no violations were identified.
8909180014 890906 PDR ADOCK 05000.289
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1. t, Fuz:,unnel Contacted 1.1 Licensee Fu m uel
- J. Bevelacqua, Manager, Safety Review Group
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G. Frank, Supervisor, Instrument calibration W. Heysek, Licensiry, Unit 2
- R. Hounes, Radioloalcal Health
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- G. Edehn, Director, Site Operations, Unit 2 S. I.svin, Defueling
G. In3de, Manager, Radiological Health, Unit 1
W. Marshall, Plant Operations
D. Merchant, Radiological Ergineer, Unit 2
A. Palmer, Manager, Radiological Controls Field Operations, Unit 1
A. Paynter, Isad Group Radiological Controls Supervisor, Unit 2
C. Pollard, Manager, Radiological Controls Field Operations, Unit 2
- M. Roche, Director, 'IMI Unit 2 R. Rogan, Director, Licensing and Nuclear Safety
- R. Wells, Licensing, Unit 2 D. Turner, Director, Radiological controls, Unit 2 1.2 NRC Personnel
- T. Moslak, Resident Inspector Denotes attendance at the exit meeting on July 28, 1989.
2.0 Organization, Staffing and Qualifications Recently the radiological controls staffing level changed significantly.
% e previous organization included the following staff:
. Director, Radiological Controls
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. Manager, Radiological Controls Field Operations
. Manager, Radiological Engineering
. Isad Group Radiological Controls Supervisor (GRCS)
. GRCS - (7)
. Radiological Controls Technician - (64)
. Radiological Engineers - (7)
he total staffing level for the department was 82 people. The current organization remains essentially unchanged but the staffing level has been reduced. W e Radiological Engineering Manager position is currently vacant and it was not clear, during the inspection, whether that position will be
. filled or remain vacant. S e number of GRCS personnel was reduced by one, from 7 to 6. S e radiological engineering staff was reduced from 7 to
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l 5, and the technician staff was reduced from 64 to 33. We total staff is currently 47 people. h e biggest reduction has been in the number of technicians, which were reduced by roughly a factor of two.
The licensee stated that the reductions in staff were prompted mainly by a reduction in work scope in Unit 2 Balance of Plant (IOP) work.
Specifically, the li nsee stated that the effort to decontaminate certain cubicles in the BOP to post defueling status has been halted for the time beirg. We licensee also stated that there is less preventive maintenance being done in Unit 2. Rese reductions in work scope have also led to a reduction of waste management efforts, and there is therefore currently less demand for health physics coverage in the BOP. 'Ihere was insufficient data, at the time of the inspaicion, to evaluate the couespoixlence between the reduction in job work scope and the size of the staff reductions.
W e licensee's Technical Specifications requires that personnel qualifications meet the requirements of ANSI N18.1-1971 for those positions for which the ANSI standard applies. The qualifications requirements for the Radiological Controls Field Operations staff is also contained in Procedure 9100-AIM-2622.01, " Radiological Field Operations Personnel Qualifications / Training Standards". According to these standards vrl procedures, the senior radiological controls technician (RCT) must have a minimum of two years of applicable experience arxl the GRCS four years. A review of the selection process used by the licensee to appoint RCTs and GRCSs, as well as a review of their qualifications, indicated the following areas for improvement:
. Were are no clear policy statements indicating the type of experience that may be accepted toward appointment to RCT or GRG.
. The maximum rate at which experience may be accumulated is not specified.
. Were is no policy statement reganling the minimum nuclear power experience required.
. The tirements for formal training are not specified, nor is the policy for us formal training as a substitute for experience.
. We manner in which Navy experience is to be credited is not specified.
A review of the qualifications of the current staff showed that the staff does meet the minimum requirements specified in the Technical Specifications and in the procedure. Hcrwever, many of the resumes reviewed had not been updated since 1985. W e licensee stated that those resumes belonged to RCTs and GRCSs who have been working at 'IMI since the last resume entry. We resumes also shcrwed that at the time of their appointment, some technicians were appointed as senior technicians without any prior commercial nuclear power experience. W e experience in such cases
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l was gained either in the Navy or as technicians in a non-nuclear, radiological operation. There were also instances in which formal training was used as a substitute for some of the required experience.
The same concerns regarding appointment and qualifications practices had
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L been raised during a previous inspection of the Unit 1 program (Inspection Report 50-289/88-19). Resolution of these concerns has not yet been j
reviewed.
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3.0 Iaundry The contaminated la'
generated on site is processed by a ocxnmercial vendor. The laundry cles from Units 1 and 2 are prmanmad separately and remain segregated. They are also subject to different allwable clean laundry contamination limits. The limit for Unit 1 is 1000 cpn and for Unit 2 is 3000 cpm. The higher limit used for Unit 2 was selected to reduce the rate of rejection of laundered protective clothiry. The licensee evaluated the veMor's capabilities for detection of contamination and has established alarm limits for the vendor's detection systems. These limits include assumptions regarding the detector-clothing distance, detector efficiency, conveyor belt speed, and other patcu#wrs. A review of the lauMry system shwed the follwing weaknesses:
. The 3000 cpm allowable contamination limit used for the Unit 2 clean laundry may be causing some of the contamination observed on site. There I
was no quantitative data at the time of this inspection to allow estimation of the magnitude of the problem, but reports generated by the licensee indicated that floor contamination has been observed around containers
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used to store laundered articles of protective clothing. The reports also indicated that contamination has been found in the passageways used by workers to go from the protective clothing dressout facility, which was outside the radiological controls. area and where clean protective clothing was donned, to the health physics control point. The licensee stated that they are now using paper undergarments to minimize the possibility of contamination being transmitted from the protective clothing to the worker, either from clean laundry or while removing PCs after working in contaminated areas. Nevertheless, licensee data iMicates that there are still frequent contaminations of these paper undergarments. The relative contribution to these incidents from laundered contaminated clothing and from poor undressing techniques was not clear from the available data.
. There currently is no systematic quality control ptWtma over the laundry
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vendor to ensure that the licensee's requirtd limits are being met aM that the contract conditions are in fact being implemented. There are no regularly scheduled and required vendor audits.
. There is no specified procedure or established protocol for checking clean lauMry to ensure that the contamination levels are acceptable. The
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licensee' stated that they do randomly check a selection of clean laundry from each returned batch. However, the number checked, and the manner of checkirg, that is, checkirg of seams and checking both the inside and outside of the articles, is not specified.
4.0 Training-h licensee has implemented, and continues to implement, a number of trainire pr@taus on hot particle contamination control. h swtaus are.
in the form of short talks given to all radiological workers who work in hot particle contamination areas and also to the staff of the radiological controls department. Se prtgram has, to date, consisted of two sets of presentations. W e first presentation is a 2-hour lecture called " Hazards from hot particles (skin dose problems)" offered by the training department. Bis lecture was designed for the health physics personnel and a review of the training records showed that all the technicians currently on staff at Unit 2 have attended this lecture. We second part of the trainire program consists of a one hour seminar designed for the radiation worker and presented jointly by Radiological Engineering and Operations.
h first half of the seminar is a lecture about the nature of hot particles, their detection, and their effects on the skin. W e second half of the seminar is an open discussion in which an operator discusses good work practices in hot particle areas and solicits responses and suggestions from the attendees. Se operator is. selected to be an individual who works in hot particle areas and is aware of the problems associated with this kind of work. He is also trained before the seminar. mis seminar series was still being conducted at the time of this inspection and is expected to continue until all affected workers have attended.
S e licensee also stated that they invited an individual fram another site, which has encountered exceptionally severe hot particle problems, to review their pr@tcuu and make suggestions. h licensee stated that some of
.these suggestions have been adopted.
B e training program appears to be adequate in that it increases awareness of the problem and provides suggestions for goud practi s when working in hot particle areas. However, based on a review of the course contents and objectives, the program offered to the health physics technicians did not include sufficient detail on the variety of pr@ taus that have been used in the industry to control the spread of hot particles, me course mainly
emphasized the definition, detection, and biological effects of hot particles and how to perform dose calculations. It also appears that the training effort for the radiological workers needs to be improved. Several licensee reports and incident analyses suggest that an important factor in the observed spread of contamination is poor techniques in contaminated areas, particularly in renoving protective clothing. The licensee stated that a radiological engineer met with all workers involved in defueling support and discussed with them methods for contamination control.
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5.0 Whole Body Friskers and Ibrtal Monitors he licensee uses a series of whole body friskers and portal monitors at various stages of the exit route fram the radiological controls areas (RCA). Whole body friskers are used at the exits from the RCA. Portal monitors are used at the exit from the health physics control point and at the exit from the Unit 2 protected area (known as Search 2). In addition, hand friskirq is also requirud at same locations, me calibration and source check records for the whole body friskers ard monitors were reviewed, as well as the set up ard calibration procedures for these systems. We records showed that the required checks were being performed at the required frequencies, and that the instruments were being operated within the specified parameter values. However, scme areas of concern were identified.
. S o whole body friskers are computer based systen.s that reguire input of a number of parameters that determine the frisker's sensitivity, mere were no documents available for inspection to support the parameter values in use. We licensee stated that such a document is available but that it was not immediately accessible for inspection his will be reviewed during a future inspection.
. W e frisker calibration procedure requires that a sensitivity check be made to ensure that the various detectors in the system will alarm at the specified sensitivity. However, the records did not show that these sensitivity checks were beirg made. %e licensee stated that the checks were in fact being made but that the current practice did not require a record to be kept.
. H e frisker calibration procedure states that a sensitivity check is to be made but it does not describe the manner in which that check is to be performed. Since this is a fairly cceplex ard sensitive check, uncertain results should be expected if each technician performs the check in a different manner. We licensee stated that the procedure will be modified to include the details of this test.
. W e sensitivity check is required by the calibration procedure to be performed on a quarterly basis. However, since the system is camputer based, any error in entering the parameters in the camputer would likely lead to an unsuspected change in sensitivity. Discussions with personnel involved in the operation ard maintenance of these systems indicated that many people have access to the data entry systems on these detectors and that there have been instances in which ins uper data was entered by untrained personnel which resulted in changiry the sensitivity. For these reasons, it may not be adequate to perform sensitivity checks on a quarterly basis. It may also be nemry to restrict access to the data entry portions of the machines and to require verification of sensitivity whenever data entry is performed. We licensee stated that they will consider these concerns ard take corrective action where appropriate.
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- 6.0~ Contamination Control me major source of hot particle contamination to date has been the Reactor Building (RB) due to the ongoirq defueling work. %e major effort at contamination control has been directed at the exit point frm the RB. his includes the containment airlock, the C-cube, and the anterocan. Personnel leaving the RB via the airlock first enter the C-cube. his is a large plexiglass-enclosed area that surrounds the airlock exit and is used for removal of protective clothing. From the C-cube, personnel proceed to the anteroom, which is the large room that contains the C-cube. Supervisors and other personnel may observe activities in the C-cube frm the anteroom. From the anteroom, personnel proceed through several stages of friskers and portal monitors before reaching the health physics control point and prior to exiting the radiological controls area (RCA).
We method used the licensee to control the spread of contamination frum the RB is to re workers to remve their vinyl boots before moviry from the RB to the a rlock. Black booties are remcr/ed before leaving the airlock to go into the C-cube. In the C-cube, the worker steps onto a grating and is vacuumed by attendants who man the C-cube area to assist workers going into and out of the RB. We protective clothing (PC), belts, radios, dosimetry, ard other articles that may have been carried by or on the worker are vacuumed. After vacuuming, the worker steps off the grating and, while still in the C-cube, removes all PCs and frisks articles to be carried out of the C-cube. Re worker then enters the anteroom ard passes thruugh a whole body frisker on the way to the HP control point. From there the worker frisks hands and feet an:1 then passes through a portal monitor before exiting the RCA. We worker then proceeds across the +urbine building to the dressing area where personal (street) clothes are left when entering. The licensee stated that several improvements to the system of contamination control have been introduced in the recent past based on experience with hot particle and other contamination incidents. Rese improvements included the following:
. The dressing area for putting on PCs used to be in the Turbine Buildirg (TB). Workers would put on their PCs and then walk across the TB to the RCA. However, it was found that the walkways used for that purpose in the TB were becoming contaminated, probably by contamination from the clean
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PCs. As.a result, the PC dressing area was moved close to the anteroom and the HP control point.
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. Workers were allowed to leave the C-cube while still in their paper modesty garments, which are worn under the PCs. However, a large fraction of these paper garments were found to be contaminated after removing the PCs, either due to contact with the outer layers of PCs or because of poor undressing practices h e licensee believes that the latter is the likely cause. 'Ib correct this problem, workers are now required to remove the paper undergarments before leaving the C-cube.
. We pre-job briefing for RB entries was augmented to include a video tape showing the proper method to remove PCs.
. W e ventilation pattern in the C-cube was changed to ensure that the air flow was from clean areas to contaminated areas, rather than the other way around, which was the case before this modification.
. Rugs have been installed at the exits from the RCA. W e licensee stated that these rugs act as good traps for hot particles and help prevent their spread beyond the RCA.
. Hot particle s are performed each shift. Wese surveys include all areas that are ect to contamination.
. Sticky pads have been installed at the exits from the anteroom arxi the control point.
. W e vacuum cleaner in the C-cube previously was used only on respirators.
m is was expanded to include other items carried by the workers, as well as the workers themselves.
In addition to the above, efforts are being made inside the RB to minimize the amount of contamination carried from the RB into the airlock. mese efforts include careful cleaning of all items renoved fran the reactor vessel, removal of outer booties as workers transit from a contaminated area to one that is less contaminated, ard wiping of outer surfaces of PCs with damp paper towels to remove gross contamination.
Although these efforts appear to have reduced the amounts of contamination found outside the RB, they do not appear to have been sufficient. As the next section of this report documents, there are still a large number of hot particles found regularly outside the RCA and a significant number of incidents of hot particles found in uncontrolled areas. Efforts at contamination control inside the RB by the use of step-off pads and other zoning neasures appear to have been unsuccessful. W e licensee's surveys and re rts indicate that all areas of the RB in routine use are highly I
con-ted and that the step-off pads are as contaminated as the other high traffic areas and do not serve to segregate regions of different contamination levels. W e licensee's reports also indicate that decontamination efforts in the RB have been sporadic and are not part of a
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routine and ongoing contamination control program. The licensee stated that they are considering a number of measures which may impmve the contamination situation in the RB.
7.0 Hot Particle Contamination Incidents Approximately 985 hot particles were found outside the RB during the first
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six months of 1989. Of these, about 890 were found in the air lock, the i
C-cube, and the anteroom (all of which are classified as beirg part of the
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RB), 26 were found in the Auxiliary Building, and 31 in the Fuel Hardling j
Building. The remainite particles were fourd in other areas such as the HP
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laboratory, Instrument shop, and Turbine Building. Most of these particles were fourd during routine contamination surveys. There were 10 skin contaminations during the same period, and 30 clothing contaminations. Most of the particles were found to contain mixtures of Cs-137 and Sr/Y-90 or only Sr/Y-90.
During the same period, 16 hot particles were found outside the RCA, and the activities of these particles ranged from about 6,000 to 25,000 disintegrations per minute (dpm). In addition, some carpet areas outside
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the RCA were found to be contaminated to levels of 1000 - 20,000 dpm. Most of these contaminations were found durirs routine contamination surveys outside the RCA, but some were found on personnel as they passed through the portal monitor in the guartl house at the exit from the protected area.
The licensee stated that they do not know how these particles escaped from the RCA since all personnel must pass through portal monitors and whole body friskers when leaving the RCA. The licensee also stated that many of these incidents occurred before the charges in the contamination control prrqram outlined in Section (6) of this report were put into effect. A review of the statistics shows that the contamination incidents did peak duringthemonthsofFebruaryandMarch(239and225 incidents, respectively) but the average number of 2ncidents has remained steady since then at roughly 130 - 150 particles per month with no evidence of a
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continuirg downward trend.
8.0 Incident Involvirp A Suspected Airborne Intake This incident occurred on the evenirs of July 26, 1989. The worker involved was a service crane operator who had been working in the RB at the time.
Upon leaving the RB and removirg his PCs, the HP technician noticed that the worker's breathing zone air sampler was dirty, indicating that dusty l
air may have been drawn through the filter. Measurements on the filter
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ebowed that it was radioactive and that the activity was distributed and not due to a hot particle. It was estirated that the activity on the filter represented about 80 MPCH (this is the activity that would result from inhalation of contaminated air at the maximum concentration given in 10 CFR Part 20, Appendix B for a period of 80 hours9.259259e-4 days <br />0.0222 hours <br />1.322751e-4 weeks <br />3.044e-5 months <br />). The worker had entered the l
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RB at 11:06 pm and exited at 1:59 am, for a stay time of 173 minutes. HP technicians took a nasal smear fmm the worker after firdirg the
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contaminated air sample. The smear did not show any radioactivity and the I
worker was sent home. The worker was counted on the whole body counter at appmximately 9:30 pm the next evening. The count showed no radioactivity in the body.
l The licensee held a critique on July 28 to investigate the incident. The critique was attended by the worker involved, the HP technicians and other
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members of the radiological controls staff, ard members from the I
maintenance department and other gmups. It was also attended by the NRC
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inspector. During the critique, the worker described what happened and j
several atterdees asked questions. Corrective actions were then propcud at
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the end of the meeting. Based on the worker's description of the incident, j
he was performing his normal crane operator duties on that day. At one
point during his stay in the RB, he rummaged through a drum containing
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highly contaminated trash looking for a can of a campourd used to secure j
nut and bolt assemblies. He stated that he could not find the can and believed that it may have been inadvertently thrown into the trash. The I
trash consisted mainly of highly contaminated towels used to wipe down
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p m onnel and equipment to reduce the contamination levels. It is believed
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that the worker's breathirq zone sample was contaminated during this
activity. The worker also stated that about 150 minutes after entry into
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the RB he started having problems with his respirator. He stated that he
felt that the air flow through the respirator had diminished, and then the j
respirator facepiece lens started to fog up to the point at which I
visibility was impaired. The worker notified the Command Center of these l
problems about 15 minutes before he exited the RB, ard he also told them that he thought he could continue workirg to finish the job he was ergaged in. The Command Center told him to continue till he finished what he was doing. The Command Center is a facility on the Turbine Deck of Unit 2 that i
is equipped with closed circuit TV monitors that view various areas of
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containment and is manned continuously by personnel sto control activities
in the RB.
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The critique was well attended and the discussions were sufficiently detailed to bring out all the details of the incident. The worker was also appropriately chastised for engaging in such an unauthorized activity, ard
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one contrary to good radiological practices, as rummaging through a contaminated waste container. However, the following concerns were noted by the inspector:
. The control and procedural aspects of the incident were not emphasized I
and solutions to these problems were therefore not considered. The Commard Center apparently did not exert sufficient control over the worker's activities to notice that he was engaged in an unauthorized activity. It was not clear fram the discussions in the critique whether this activity was within the field of view of the TV monitors in the Canmard Center and, if not, whether this could be a problem.
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. We Commard Center was made aware by the worker that he was having problems with his respirator yet they did not order him to leave as soon as possible. Instead, the worker was told that he may finish what he was doing and then leave. Based on the discussions during the critique, the worker indicated that he stayed on to finish his work so as not to let dwn the other members of his work team. According to station procedure 9200-AIM-4020.03, "Use of Respiratory Protection Equirnent", ".. if a respirator user experiences equipment malfunction, he rhould secure his work station and leave the area. W e respirator is removed only if it is remry to perform the exit in a safe mmner." h e licensee stated that the worker actually did need 15 minutes to secure his work station.
H wever, based on the worker's description of the event during the critique, this was not the case. W e worker could have left the area much earlier than he did. W e need for a quick exit from the area at the first indication of respirator problems was critical because the worker was wearing a pwered air purifying respirator of the kixun as a for whom a tight
"Breezer". mis type is used by the licemee for wor o
facepiece seal is difficult or impossible to achieve with any of the
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available tightfitting facepieces. One of the limitations of the Breezer is that the hood volume provides approximately 2 minutes of breathing air follovirs failure of the blower. At the end of the two minute period, the respirator must be removed. Had the blova failed during work in the RB, the worker may have had to remove the respirator before he had time to exit the building. Although the atmosphere in the reactor building was breathable, the worker's protective clothing and headgear were apparently highly contaminated both as a result of his normal work activities ard also his search in the contaminated trash. Removing the respirator quickly under these conditions may have resulted in a significant possibility for an intalm of radioactive material.
. Health physics penonnel were not asked to be involved in the situation by the Command Center after they were notified by the worker that he was having respirator problems. Health mysics personnel were not notified until the incident was over.
. Accordirg to procedure 9100-AIE-4025.01, " Bioassay Procedure", "A whole body count is required foll wing any event which indicates a respirator failure durirg radiological work, unless air sampling results can adequately demonstrate that MPC-hour assignments resulting frum the failure are less than the values stated in section 4.2.5 of this procedure (over 2 M K-hour in one day or over 10 MPC-hour in a calendar quarter)". We worker was counted on the whole body counter one day following the incident. S e decision not to count him immediately was based on the fact that a nasal smear, taken after renoval of the respirator, did not show any radioactivity ard it was therefore concluded that there was no intake. Se procedure, however, does not address such situations adequately. It does wt specify the use of nasal snears as a test of the urgency of obtaining a whole body count. The procedure also does not clearly specify the urgency of getting a whole body count following discovery of one of the unditions that would require such a count, it only states that a caunt must be made.
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%e above considerations wem not brought out in the critique, and wem therefore not ived as problems and were not addressed. %e main corrective a ons that were agreed upon at the end of the critique were to reconsider the use of the "Breezer" respirator, considerira the difficulties that workers have been experiencing in their use, and to enphasize to the worker that his search through the cart.aminated waste was an act of poor judgement arri should not be repeated. he problem of licens,ee critiques focusiry narrmly on an incident and not addressing procedural deficiencies connected with the incident has been addressed previously in NRC combined Inspection Report 50-289/88-12 and 50-320/88-09.
9.0 Btit Meeting E e inspector met with licensee representatives at the end of the inspection on July 28, 1989. Tne inspector reviewed the purpose and scope of the inspection and discussed the inspection findings.
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