IR 05000293/1986019
| ML20212A388 | |
| Person / Time | |
|---|---|
| Site: | Pilgrim |
| Issue date: | 12/05/1986 |
| From: | Baum J, Ronald Bellamy, Cioffi M, Nimitz R, Shanbaky M, Sherbini S NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML20212A341 | List: |
| References | |
| 50-293-86-19, NUDOCS 8612220390 | |
| Download: ML20212A388 (29) | |
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U.S. NUCLEAR REGULATORY COMMISSION
REGION I
Report No.
50-293/86-19 Docket No.
50-293 License No. DPR-63 Priority Category C
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Licensee:
Boston Edison Company., M/L Nuclear 800 Boylston Street Boston, Massachusetts 02199 Facility Name:
Pilgrim Nuclear Power Station Inspection At:
Plymouth, Massachusetts Inspection Conducted: October 20-24, 1986 Inspectors:
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M. Shanbaky, Chief, Facilitie V date Radiation Protection Section, Team Leader
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lthIEL R. L. Nimitz, Senior Radiation Specialist date k.
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'S. Sherbini, Radiation Specialist date
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R.L. Nd b 12. g l St J. Baum, Manager, ALARA Chr?ter, cate l
Brookhaven National Laboratory
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Approved by:
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R. R. Bellamy, Chief, Emergen date'
Preparedness and Radiologi rotection Branch
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j Inspection Sumn ary:
Inspection on October 20-24, 1986 (Report Number j
50-293/86-19)
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Areas Inspected:
Special, announced Health Physics Appraisal to evaluate the licensee's upgraded Radiation Protection Program developed in response to an NRC Order Modifying License dated November 19, 1984. Areas reviewed were:
management oversight and control; organization and staffing, training and qualification; external and internal exposure controls; radiological surveillance; ALARA; radioactive material control, and radiation protection facilities and equipment.
Results: No violations were identified. Significant program weaknesses were identified and discussed in this Inspection Report.
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1.0 Executive Summary On November 29, 1984, an Order Modifying License was issued to Boston Edison Company.
The Order required:
(1) the completion of an independent contractor assessment of the Radiological Controls Program at Pilgrim Station; (2) the submittal to the NRC of contractor assessment reports; (3) the establirtment of a Radiological Improvement Plan (RIP) to address contractor identified deficiencies; (4) submittal of the RIP to the Regional Administrator for review and approval prior to its implementation and; (5) the establishment and implementation of an Interim Plan for achieving adequate management oversight and maintaining sufficient radio-logical control of work in progress until RIP action items are completed.
All RIP action items were to be completed by December 30, 1985 unless otherwise justified in writing to the Regional Administrator, Region I.
An independent contractor assessment was performed. The results of the assessment were provided to the Regional Administrator, Region I, in a February 28, 1985 letter. An Interim Plan was included with the February 28, 1985 letter as was the Radiological Improvement Plan (RIP).
The RIP was approved for implementation in a March 15, 1985 letter from NRC Region I.
With few exceptions, the RIP milestones were implemented.
Extension requests and appropriate justifications were provided for those milestone that could not be met as indicated in the RIP.
The findings of the appraisal indicate that staffing, administrative and procedural improvements have been made to the radiological controls program at Pilgrim Station.
Improvements include: an expanded radio-logical control organization; upgraded procedures; and an improved radiological controls personnel training program.
However, although administrative and procedural improvements have been noted, additional management attention is needed to:
improve communica-tion and working relationships between the radiological controls section and other sections; establish vigorous accountability of individuals and groups for deficient conditions or actions, establish a Station Radio-logical Controls Goals Program which challenges all station groups to maintaining exposure ALARA; implement timely, lasting corrective actions for identified deficiencies; and improve overall management oversight and supervision.
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DETAILS 2.0 Individuals Contacted l
Boston Edison Company
- L. Oxsen, Vice President Nuclear Operations
- A. Pedersen, Plant Manager
- K. Roberts, Director Outage Management
- A. Morisi,-Assistant Director Outage Management l
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- W. Deacon, Assistant to Chief Operating Officer l
- T. Sowdon, Radiological Section Manager l
NRC
- R. Bellamy, Chief, Emergency Preparedness and Radiological Protection Branch
- M. McBride, Senior Resident Inspector
- Denotes those individuals attending the exit meeting.
Other individuals were also contacted.
3.0 Purpose and Scope of Appraisal 3.1 Purpose The purpose of this Appraisal was to determine whether the licensee has fully established and implemented an effective Radiation Pro-tection Program in response to the NRC Order Modifying License dated November 29, 1984. The Order was issued on the basis of poor en-forcement history and the identification of significant Radiation Protection Program problems. The Order required an independent review of the entire Radiation Protection Program and correction of iden-tified problems.
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Progress towards the development and implementation of an upgraded Radiation Protection Program was followed and documented in the following Inspection Reports:
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Report 85-13, dated July 16, 1985
Report 85-22, dated October 7, 1985 Report 85-32, dated December 31, 1985 Report 86-02, dated March 10, 1986
Report 86-16, dated May 23, 1986 3.2 Scope The following areas were reviewed and evaluated during the Appraisal:
Licensee Action on Previous Findings i
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- Management Oversight and Control
Organization and Staffing
Personnel, Selection, Qualification Training and Retraining
External Exposure Controls
Internal Exposure Controls
Radiological Surveillance Program
ALARA Program
Radioactive Material Control Program
Radiation Protection Facilities and Equipment 4.
Licensee Action on Previous Findings 4.1 (Closed) Follow Item (50-293/85-32-13).
Licensee to establish and implement a procedure to provide guidance for the determination of intake from in-vitro analyses.
(RIP Item 6.1.1-1)
Procedure 6.2-161, Revision 9, Section J, specifies that in-vitro sample results will be evaluated using methodologies described in the appropriate Standards and Regulatory Guides.
4.2 (Closed) Follow Item (50-293/85-32-15).
Licensee to review pro-cedures and resolve discrepancies in inte'rnal deposition and external contamination action levels.
The licensee revised procedure 6.2-161 revision 9, to clearly establish internal deposition action levels.
Procedures SI-RP.1100 "MPC-Hours Determinations", SI-RP.2100
"In-Vitro Bioassay Program", and SI-RP.4103, " Operation of the Whole Body Counter" were reviewed.
The procedures were found adequate.
(RID Item 6.2.1 g-1)
4.3 (Closed) Follow Item (50-293/85-32-16) Licensee to develop procedure that includes the approved methods and calculations for determining intake of radioactive material via in-vitro analysis.
Procedure SI-RP.4103 was revised to instruct the whole body counter operator to calculate MPC hours based on Cobalt-60 intake and conservatively assume a lung deposition of 12.5%. Additionally, the procedure es-tablishes action levels and required actions for various trigger
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investigation levels from 3% Maximum Permissible Organ Burden (MP08)
and above.
The licensee stated that refined MpC hour calculations will be performed by the technical staff using the appropriate regulatory guides and calculational methodologies.
However, this latter guidance was not clearly established in the procedure.
This matter is discussed in Section 9.2 of this report and is closed for administrative purposes.
4.4 (Closed) Follow Item (50-293/85-32-19) Licensee to develop a program for the routine comparison of air samples, whole body count and respiratory protection data to provide verification of the effective-ness of the internal exposure control program (RIP Item 6.2.2.e).
The licensee developed an Internal Checks Program Chart to track,
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trend and compare all data used for internal exposure control.
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However, the implementing procedure has not been written. This matter is discussed in Section 9.2 of this report and is closed for administrative purposes.
4.5 (Closed) Follow Item (50-293/85-32-29) Licensee to establish and implement procedures for an ALARA Program and incorporate ALARA requirements into radiation work permits. The licensee incorporated ALARA requirements into the radiation work permit program.. However, all ALARA procedures have not been approved.
(RIP Item 9.1.1-6).
This matter is discussed in Section 11 of this report and is closed for administrative purposes.
4.6 (Closed) Follow Item (50-293/86-02-11) Licensee to ensure adequate procedures in place to implement the Radioactive Material Centrol Plan. This matter is discussed in Section 10. Certain procedures are not-in place.
(RIP Item 12.1 and 12.2-4).
This matter is discussed in Section 12 of this report and is closed for administra-tive purposes.
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4.7 (Closed) Follow Item (50-293/85-32-34) Licensee to establish and implement Radiological Section Goals. The radiological controls aroup goals include a number of station goals which are out of the control of the radiation protection group. Also, the group goals are not comprehensive. (RIP Item 13.3.1-1).
This matter is discussed in Section 5 of this report and is closed for administrative purposes.
4.8 (Closed) Follow Item (50-293/85-22-16) Licensee to upgrade his corrective action system to provide for implementation of timely corrective action to prevent recurrence. (RIP Item 14.1-1) The licensee has upgraded his corrective action system to provide for timely review of events. However, problems continue to recur indicating ineffective implementation of the corrective action process and lack of aggressive management action to prevent recurrence. This matter is discussed in Section 5 of this report and is closed for administrative purposes.
4.9 (Closed) Follow Item (50-293/85-13-07) Licensee to formally define the approved organization structure for Radiological Controls Organ-
ization. The licensee formally established, approved, and
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implemented a new, defined Radiological Control Organization.
The position descriptions and responsibilities have been defined.
This matter is discussed in Section 5.
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4.10 (Closed) Follow Item (50-293/85-32-03) Licensee to complete staffing of exempt position in the radiological controls organization. The licensee has filled the positions of Chief Radiological Engineer and Environmental Radiological Health Services Group Leader. However, one position remains unfilled - Senior Radiation Protection Supervisor-
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ALARA. This matter is discussed in Section 6 of this report and is
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closed for administrative purposes.
4.11 (Closed) Follow Item (50-293/85-32-05) Licensee to establish a formal continuing training program for all Radiological Group personnel.
The licensee established a continuing training program for radiological group personnel. This matter is discussed in section 6 of the report.
4.12 (Closed) Follow Item (50-293/85-22-10) Licensee to implement the revised radiological portion of the General Employee training program. The licensee was also to review the need to expand the Radiological Occurrence Report discussion and the discussion of the Radiological Control Group structure.
The licensee implemented the revised GET Program. The program was found to contain an adequate description of the ROR Program and Rad group structure.
The GET Program is INP0 certified.
(RIP Item 3.1.1-3)
4.13 (Closed) Follow Item (50-293/85-32-06) NRC to review documentation demonstrating that a radiological group member reviewed course material developed for Health Physics personnel.
The licensee provided documentation demonstrating the review was performed.
(RIP Item 2.2.4-1)
5.0 Management Oversight and Control 5.1 General The adequacy and effectiveness of Management Oversight and Control of the Radiation Protection Program at Pilgrim Station was reviewed.
Specific areas reviewed were as follows:
Implementation and adequacy of Improvement Items as described l
in Boston Edison Radiological Improvement Plan, Chapter 13, Management Oversight, and Chapter 14, Corrective Action System.
- Adequacy and effectiveness of the Radiological Control Organization Inter and Intra section communication l
l Performance Monitoring including goals development
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- Licensee performance in this area was determined through discussion with cognizant personnel, review of performance monitoring documents, and review of procedures.
5.2 Documents Reviewed Executive Management Information Report - Performance Monitoring, Nuclear Management Services Department.
- Nuclear Operation Procedure, NOP 8SA1, Nuclear Organization Performance Monitoring and Management Corrective Action Process, dated August 1, 1986.
- Nuclear Organization /olicy #37, Performance and Accountability.
- Nuclear Operation Procedure, N0P 8SA1, Nuclear Organization Performance Monitoring and Management Information Program, dated August 8, 1985.
Nuclear Operation Policy, N0P 83A13, Deficiency Report Process.
- Nuclear Operations Department Procedure No. 6.1-209, Radio-logical Occurrence Reports, dated April 28, 1986.
Pilgrim Nuclear Power Station, Radiation Protection Plan.
5.3 Findings Although management oversight, control and attention to the Radiation Protection Program at Pilgrim station has improved, significant communications and working relationship problems between station groups continue to be noted.
Efforts are ongoing to improve com-munications at all levels of the organization, improve morale, improve working relationships between station groups, and track and monitor key indicators of personnel and work group performance.
Certain administrative and procedural changes have been realized through enhancements in the following:
The Radiation Protection Organization was reorganized.
Position descriptions and functional responsibilities were defined.
The organization chart, position descriptions and functional responsibilities were distributed and posted.
- The previously vacant position of Chief Radiological Engineer was filled by a qualified individual with radiological controls
experience received at other BWRs. Additional personnel with BWR experience at other facilities have been hired.
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The Radiological Occurrence Report Program has been formally incorporated into the management corrective action process.
The Occurrence Repor:s are now subject to biannual Nuclear Safety Review and Audit Committee audits.
- A task assignment tracking system has been established and implemented within the Radiation Protecticn Section. Manager task assignments are computer tracked to resolution.
An approved Radiation Protection Plan has been established.
The plan provides policies, objectives, standards and methods to implement and maintain the Radiological and Environmental Program. The plan includes an audit program to evaluate the implementation and effectiveness of the Radiation Protection Program.
Procedures have been established to implement the plan.
A Radiological Contrels Supervisory Tour Program has been established.
Reviews of plant conditions, on going work, and personnel awareness of radiological requirements is monitored during tours.
An expanded plant performance monitoring program, utilizing key performance indicators, was developed. A monthly report of performance is provided to senior management.
Twenty-eight indicators in eight functional areas including radiation protection is provided. A number of the indicators are INP0 performance parameters.
- Initiatives to improve inter and intra departmental communica-tions were on going.
Station management is meeting twice a week with section managers to discuss problems and concerns. Daily plant briefings are attended by section heads and key radiation protection personnel.
Daily radiation protection staff meetings are held to discuss current activities.
Radiation Protection Section personnel attend outage and main-tenance planning meetings.
Radiation protection personnei now receive copies of outage / maintenance planning schedules.
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The documentation of management oversight and control of the radia-tion protection program has improved.
Radiation protection Program procedures and staffing has been upgraded. However, the folicwing significant program weaknesses were brought to the licensee's atten-tion as areas needing improvement:
(50-293/86-19-01)
Communications and working relationships between the Radiation Protection Section and other station sections, particularly the Operations Section, needs improvement. This continues to degrade morale with potential impact on operational and radiological safety.
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The licensee is acutely aware of this problem and is taking steps to address it.
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The station and section goals program needs upgrading. The current performance monitoring program does not stress account-ability when goals are not achieved. Also, some important parameters do not have accompanying goals.
For example, of six radiological controls parameter included in the performance monitoring report, only two have accompanying goals.
In ad-dition, of twenty-four parameters tracked in the monthly Radio-logical Occurrence Report summary, none have accompanying goals.
Also some important parameters are not provided to senior man-agement as a performance indicator (e.g. total station area contaminated).
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Aggressive management action is needed to substantially reduce the number of Radiological Occurrences at the station.
Recur-rent problems continue to be identified by the Radiological Occurrence Report Program.
- The Licensee has completed a review of the Radiation Protection Plan and Radioactive Material Control Plan to ensure that appropriate implementing procedures are in place.
Some pro-cedural deficiencies were identified. The licensee should ensure all necessary procedures to implement the plans are established and implemented on a timely basis.
A RIP audit was conducted by the Radiological Oversight Com-mittee and by a contractor. Appropriate milestones should be established for completion of corrective actions for weaknesses identified in both assessments.
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Organization and Staffing The radiation protection organization has been reorganized. An approved, up-to-date organization chart which defines lines of authority and communication has been established.
Position descriptions and functional responsibilities are documented and distributed.
The organization and position descriptions are described in the approved Radiation Protection Plan.
Additionally, technically qualified and experienced personnel have been hired. The vacant Chief Radiological Engineer position was filled with a qualified, experienced individual. Also, additional technical support personnel have been hired to oversee program support functional areas (e.g. external dosimetry). The ALARA staffing has been increased.
Although the organization was found to be upgraded, the following items for improvement were identified:
(50-293/86-19-02)
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The current Radiation Protection Organization is not consistent with that depicted in Technical Specifications. The Technical Specifi-cation should be updated to: 1) depict the correct organization and 2) clearly identify the Regulatory Guide 1.8 qualified Radiation Protection Manager (or equivalent title).
Discussions with cognizant radiation protection personnel indicate that during outage conditions, the section directly reports to the Outage Manager and administratively reports to the Station Manager.
This arrangement is not provided for or described in Technical Specifications.
The Radiation Protection Plan does not describe functional respon-sibilities for all Radiation Protection Supervisors. The Plan serves as the primary program description document and should be updated to reflect radiation protection supervisor responsibilities.
Responsibilities in the area of radioactive and contaminated material handling need upgrading and distribution to all station sections involved with radioactive material handling, processing and storing. Consideration should be given to establishing a radio-active waste handling, processi.;g and shipping group.
An individual with experience in internal dosimetry should be obtained. Otherwise the individual supervising the internal dosimetry program should be provided additional training.
The r Jrrent individuals supervising this area have limited experience in nternal dosimetry.
The Senior Radiological Engineer - ALARA position is vacant. This position should be filled in a timely manner by a qualified individual.
- Personnel are being moved to other positions in the radiation protection technical support area. Movement of personnel in this area should be finalized in a timely manner in order to stabiliza and provide consistent oversight of technical support functional area responsibilities.
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Personnel Selection, Qualification and Training
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The personnel selection, qualification and training prog'r'am was,found.to be generally acceptable. The program was evaluated by review of control-
ling procedures, discussion with plant -anagement and training personnel, review of training and qualification re cds, interviews with Health Physics (HP) technicians of various qua, ication status, and comparison with selected industry good practice,
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In general the level of qualifications and professional credentials of the RP group and training staff were acceptable. The licensee is implementing an INP0 accredited training program. The three phase technician training program contained theory as well as practical job related elements that required a broader scope and increased depth of knowledge as the tech-nician progressed through the program. To date, two individuals have become " fully qualified" (INPO certified technicians) by completing the entire training and qualification program.
In plant supervisors interviewed did not display understanding of how on-the-job training and goals for specific tasks fit into the overall qualification program, or conversely, how the qualification level impacted on a technician's ability to perform his job in the plant. The inspector did not, however, observe any individual performing a task that they were not qualified to perform.
Technicians interviewed (both BECo and con-tractor) appeared qualified for their respective level of responsibility.
The training manual states that the 2 years experience required for a technician was met by 2 years of working as a Navy ELT, or as a radcon monitor at a military nuclear facility.
Similarly, experience require-ments for RP supervisors can be met by military experience on a one year for one year basis.
Since 1971, industry consensus standard, ANSI 3.1, has moved away from allowing a full one-for-one year allowance (recogniz-ing that non power react experience is not equivalent to commercial experience).
The curre.,
industry practice credits military experience on a 2 to 1 year basis up to a maximum of 3 years. Given that only part of an ELTs time is spent in performing Health Physics activities (the remainder is taken up by chemistry technician and plant operator duties),
a technician's experience should be individually evaluated, and health physics related experience applied on' a 2 for 1 basis to meet the 2 year experience requirements of ANSI 18.1.
In discussion with RP management, the inspector was assured that no HP contractor or BECo technician with only Navy (standard 6 year ELT tour)
experience acts as a " responsible HP technician" (e.g., performs surveys, approves RWPs, stands back shift watches without supervision). The licensee stated that they will re-examine this practice.
The Training Manual states that the one year formal education requirement of ANSI 18.1 for a HP technician is considered met by completing a tech-
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nical training course, (e.g. ELT training 3 months long and " Article 108" training generally 2-4 weeks long).
Equivalents to formal education re-quirements for the Radioiogical Group Supervisory / management personnel such as 'iompletion of certain correspondence courses" (for radiation protection supervisor) and " substantive technical training in the area of Health Physics" (for the Chief Radiological Engineer), also lack clarity.
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When a candidate does not clearly meet the established qualification for a position, he may be judged qualified based on some other considerations.
However the individual responsible for this judgement should be identi-fled, and guidelines as to what factors can be considered (such as weight of experience or augmented training) should be enumerated.
Licensee personnel indicated that the following matters would be reviewed (50-293/86-19-03):
The inspector noted that the board used for posting of notices to workers (as required by 10 CFR 19.11) at the main control point was not in a location conspicuous to individuals entering the controlled area using the access route from the Administration ouilding. The licensee stated that the board had been recently moved during facil-ity modifications and would be relocated to a more conspicuous location.
Inspector noted discrepancies between the qualification requirements specified in the training manual and those in the individual position descriptions.
The position description for the chief radiological engineer is not consistent with the qualification description in the training manual. Also, an apprentice radiation protection technician is not described in the training manual.
The training manual, section 3.5.4, describes the qualification pre-requisites for entry level.
Paragraph 3.5.4.1 states that all HP technicians hired into the Boston Edison Company will meet the ANSI 18.1 requirements. The description as to what Boston Edison con-siders adequate to meet the training and experience requirements is net consistent with ANSI 18.1.
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External Exposure Control 8.1 Radiation Work Permit System The licensee utilizes a radiaticn work permit (RWP) system to assign radiological protection controls for work activities performed in radiological areas.
Issuance of an RWP is requested by the super-visor of the work group intending to perform the work. The inspector reviewed several RWP requests and found them generally to be suf-ficiently descriptive of the i'ntended Work to allow proper radio-
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logical controls to be applied.
The inspector also noted specific instances where the radiation protection group had to return the RWP request to the submitting party for additional information. The controlling procedure.(station procedure 6.1-022) requires the RP Supervisor-operations to review the RWP for completeness and assign the survey frequency appropriate to support the activity. All RWPs reviewed by the inspector appeared to be complete.
Specified protec-tive measures and survey frequencies appeared to be commensurate with the anticipated radiological conditions.
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Approval authcrity for an RWP specified in 6.1-022 is a function of the man-rem estimated to cc,mplete the task. An RWP involving less than 5 man-rem can be approved by the RP supervisor /ALARA engineer.
Higher man-rem jobs require additional ALARA review and progressively higher level of authority for approval. At 25 man-rem, or greater, an RWP needs the radiological section head's signature for approval.
Time for this ALARA evaluation is provided by the controlling pro-cedure which establishes a graduated system (also based on man-rem estimate) to determine how far in advance of the job the RWP request must be submitted.
To ensure safe plant operation, the watch engineer is authorized to designate an RWP as "A" priority. Priority "A" RWPs are issued on short notice with as much ALARA review as is practicable under the situation.
RWPs are terminated when the RP group is notified that the work has been completed, at the discretion of the RP or ALARA supervision, or if no work has been completed under the RWP for seven consecutive calendar days.
The inspector reviewed various RWPs with associated radiological surveys, sign-in sheets and briefing sheets. Additionally, the inspector observed the RP group process RWP requests, and perform both special and extended RWP briefings. Based on this review, the licensee appeared to be implementing a comprehensive and effective RWP program.
Examination of RWP records indicated that a substantial fraction of RWPs are issued with no subsequent work performed under these RWPs.
The radiological surveys associated with these RWPs were performed at the required frequencies.
Since there was no work conducted under these RWPs, the surveys performed may contribute to unnecessary exposure.
The inspector noted that a substantial amount of documentation is required by this system. At the time of this inspection the plant maintenance work load was very light for an outage situation and did not allow for determining how the RWP system will perform under stress.
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i The following program weaknesses were discussed with licensee's management for appropriate action:. (50-293/86-19-04)
Communication between the RP group and operations and main-I tenance groups is vital for the proper operation of a RWP l
control system. The frequent use of Priority "A" RWPs, the
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large number of RWPs requested and approved that do not get worked, and the failure to notify the RP group when work is
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8.2 High Radiation Area Access Control
.The licensee's program for the physical and administrative control of personnel access to high radiation areas (HRAs) was evaluated by discussions with cognizant radiation protection and operations personnel, physical inspection of facilities, and review of selected licensee procedures, training and log books.
Based on the above review it appears that the controlling procedure (No. 6.1-012) establishes a thorough system implementing the require-ments of high radiation area access listed in the plant Technical Specification (TS 6.13). However, additional emphasis on the im-plementation of this procedure and diagnosis and correction of procedural breakdowns is needed.
Procedure 6.1-012 provides for areas of greater than 1000 mR/hr to be locked. Keys to individual locked high radiation areas (HRAs)
are controlled in the RP office.
Issuance of a key requires an active RWP for the job indicated. Additionally.five master keys controlled by and issued to RP, 4 master keys controlled by Operations, and submaster keys issued to chemistry and radwaste personnel are provided. Routine entries into these areas are covered by extended RWPs that require the individual to contact the RP group for a sign-in sheet and briefing.
In addition to the TS 6.13 requirements procedure 6.1-012 provides for areas of greater than 10,000 mR/hr to have an additional lock.
Four master keys to these "hi-hi rad" area locks (LHHRA) are controlled by the watch engineer / shift supervisor. The procedure provides for shiftly, weekly and special audits of keys to ensure accountability.
The inspector reviewed various sign-out and weekly audit sheets of high rad keys and determined the RP department is complying with the controlling procedure and maintaining accountability for LHRA keys.
Additionally the inspector reviewed key sign-out log and authorized key recipients lists maintained by operations. The Operations Department appears to be maintaining appropriate accountability for the LHRA and LHHRA keys in their control.
A physical inspection of various LHRA access points indicated that the licensee continues to have difficulty maintaining areas locked.
The inspector found one area maintained as a LHRA (RWCU room)
unlocked and unguarded.
The licensee took immediate actions that
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included locking the access gate, initiating a radiological survey to evaluate the hazard in the area, updating the RWP with a warning that the lock on the access gate sticks open, issuance of a radio-logical occurrence report (ROR) and issuance of a maintenance request to repair the lock. The radiological survey indicated that radiation levels in the area were less than 1000 mR/hr and therefore was not
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14 specifically required to be locked. However, the inadvertent nature of this occurrence indicates a weakness in the access control pro-gram. Although the documentation of the weekly surveillance of the LHRA gates indicated that this lock was functional, and the RWP sign-in sheets for the area indicated that individuals had checked the gate locked on egress from the area, it was still left in an unlocked and unguarded condition.
The inspector noted that the overall physical condition of LHRA and LHHRA access control mechanisms was good.
It was evident that the licensee has committed resources to maintain them in an operable condition. The licensee had also made an effort to minimize the nu;nber of areas controlled as LHRAs.
Recently, they had reviewed the radiological hazards in each area and downgraded (removed the locks) in those areas that warranted it.
Licensee personnel indicated the following matter would be reviewed:
(50-293/86-19-05)
Review of the 1986 RORs indicated a recurring problem with maintaining LHRA acces; points locked. The gate to the RWCU pump room found unlocked in this inspection had been previously found unlocked and unguarded by an NRC inspector this year.
Repeat occurrences of the N.W. gate on the 51' level of the Turbine Building being found unlatched were also noted. These occurrences indicate that the licensee's system for diagrosing a root cause, necessary for proper corrective action, needs improving.
In discussions with RP supervision the licensee indicated they would investigate whether they had a teneric problem with the LHRA latching mechanisms.
- During the review of the keys controlled by the operations group, the inspector interviewed one watch engineer / shift supervisor, a senior reactor operator and the technical assistant involved in LHRA key issuance. The watch engineer interviewed displayed a lack of knowledge of the control and issuance procedures of the keys administratively under his control. A review of the key issuance log did not indicate the any key was issued to unauthorized personnel.
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Controlling procedure 6.1-012 does,not reflect the requirements
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for entry into h,igh radi& tion areas specified in TS 6.13.1.
This procedure leads the reader to believe that continuously indicating radiation monitoring devices are only required for entrance into areas of greater than 10,000 mR/hr contrary to the TS (which require them in areas of 100 mR/hr or greater).
Although these requirements are listed in the RWP issuance procedure (No. 6.1-022) referenced in 6.1-012, this may lead to
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some confusion with plant personnel. During GET for initial access to the plant, the NRC inspectors were told by the instructor that having a continuously indicating monitor was in fact not required unless entering an area of greater than 10,000 mR/hr.
8.3 External Dosimetry Areas inspected included staffing, qualifications, training, pr ocedures, dosimetry issue and records, and dose assessment. The review indicated that, in general, the program was in the process of undergoing major revisions and that these revisions should result in an efficient and technically cound program. One of the areas under-going revisions is the program procedures.
Existing procedures have been revised or rewritten and new procedures have been added.
Staffing is being increased by one permanent position at the adminis-trative assistant level, and a new supervisor for the external and internal dosimetry program has been hired. The staffing level appeared to be adequate, and is augmented by contractor personnel during outages. An extensive training program is also being de-veloped for the dosimetry staff.
The program will cover all aspects of dosimetry, including theory, hardware, dose assessment, a,d site specific procedures.
It is anticipated that all dosimetry tech-nicians, currently in the program as well as newly hired personnel, will undergo training using the newly developed course material.
Dose tracking and record keeping were found to be good and appeared to provide reasonable assurance of keeping track of the quarterly
accumulated exposures of all badged individuals.
The system appeared somewhat cumbersome because it required each badged individual to carry a dose record card at all times on site, but there were no indications that this created any unusual hardships.
Self-reading dosimeters are tested, calibrated, and issued on site, but TLD dosimetry is supplied by an offsite dosimetry service, the Yankee Atomic Environmental Laboratory (YAEL). The YAEL is an independently operatea processor funded by a consortium of five New
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England utilities, including Boston Edison Company. The dosimeter
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is a Harshaw badge with two LiF chips for beta / gamma measurements and two LiF chips used in an albedo configuration for gamma / neutron
measurements.
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Quality control of the dosimetry processing operation is an internal function of YAEL and is therefore not under the direct control of Boston Edison. However, members of the consortium perform regular quality assurance audits of YAEL's operation and procedures. Boston Edison also periodically supplies YAEL with irradiated, or " spiked",
TL0s as part of the QA effort.
These TLDs have in the past been irradiated on site at Pilgrim station, but negotiations are underway to have the irradiations performed by an independent irradiation laboratory.
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Under normal operation conditions there will be no on-site TLD processing capabilities. However, arrangements have been made with YAEL to provide an on-site reader during cutages.
YAEL will also provide a reader at the EOF or other convenient location close to the site during an emergency.
A number of hardware and procedural problems are being addressed by the dosimetry technical staff in cooperation with the YAEL technical staff. These problems include determination of a suitable correction factor for skin dose assessment based on dosimeter readings, proper placement of dosimetry inside or outside protective clothing to ensure proper monitoring of skin dose, anomalous sensitivity changes in the TLD chips, and evaluation of new extremity dosimetry.
The proposed changes and upgrades in the program should result in a high quality dosimetry program at Pilgrim Nuclear Power Station.
However, many of these changes and improvement were still in progress at the time of this inspection.
The following matters and concerns were discussed with the licensee during the inspection and the licensee indicated that they are being addressed: (50-293/86-19-06)
Completion of dosimetry procedure revisions and implementation.
Complete development and implementation of the new dosimetry training program.
Completion of personnel dosimetry staffing (2 additional staff members).
- Complete resolution of outstanding technical issues as discussed above.
- Complete arrangement to perform offsite irradiation of TLD dosimeters for use in QA/QC, 9.0 Internal Exposure Control 9.1 Respiratcry Protection Program The licensee's program for respiratory protection was evaluated by review of applicable procedures, inspection of facilities, discus-sions with supervisory and support personnel, and comparison with criteria contained in applicable regulations and industry standards.
In general, the licensee's program in this area was found to be an acceptable program.
The following positive aspects and program strengths were noted.
The Supervisor, Respiratory Protection and Internal Dosimetry is actively involved in program oversigh and management.
He attended a one-week respiratory protection course and the vendor courses for
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respirator repair within the last two years. The supporting respiratory protection technicians received on-the-job training on respiratory protection procedures, and appeared to be conscientious and competent in the performance of their duties.
An active program was found in place to address and evaluate the concerns that are identified in industry publications and I&E In-formation Notices. The licensee maintains a frequent surveillance program on self-contained breathing apparatus (SCBAs) stored throughout the plant for emergency use.
Tracking and trending of weekly surveys of SCBA compressed air tank pressures is performed to identify problems with the equipment or with storage techniques.
The licensee uses Grade E breathing air for all compressed air cylinders and for supplied air. Testing of breathing air is conducted quarterly to assure air quality.
A previous deficiency was identified in which all airline fittings throughout the plant used Chicago fittings. The licensee initiated an engineering change to convert all breathing air sources used in personnel respiratory protection to Hansen fittings to eliminate the potential for hooking up supplied air respirators to an air source that was not of breathing air quality. The licensee also purchased tags to identify breathing air only air sources.
The following program areas which need improvements were discussed with licensee personnel. The licensee indicated these would be reviewed:
(50-293-86-19-13)
The licensee currently only has one size mask for respiratory protection. Therefore, there will be some individuals who will not fit properly in the standard respirator facepiece. The licensee is considering purchase of additional respirator face-piece sizes to accommodate personnel with large or small faces to ensure proper respirator fit.
Personnel who cannot be fit are not permitted to wear respirators.
- Respirators were stored more than two respirators high, and respirator head straps were pulled over the facepiece visor for storage. These two practices have been found to potentially deform the sealing surfaces of the respirator facepiece. The licensee stated that these two practices will be discontinued and respirator training will be revised to instruct workers on donning of respirators without pulling headstraps over the facepiec.o
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9.2 Bioassay Program The program for internal exposure control and determination was evaluated by review of applicable procedures, inspection of facili-ties and equipment, discussions with supervisory and support per-sonnel, and comparison with criteria contained in applicable regulations and industry standards.
Overall the in vivo (direct) program was considered adequate to meet regulatory requirements.
Elements of the in vitro (indirect) program were found to need upgrading. The in vivo bioassay program consisted of an APT chair with two sodium iodide detectors.
One detector views the lungs, and one detector views the thyroid. The inspector re-
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viewed daily background and check source data, source configuration
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to ensure reproducibility of measurements, and the procedure for full monthly equipment calibrations.
Instrument calibrations and quality control appeared to be properly implemented.
Benchmarks on the chair for positioning of detectors and sources were clearly marked.
A deficiency identified in previous audits concerning monitoring the-thyroid for radiciodine uptake was resolved.
Procedure 6.1-161, Revision 9, " Administration of the Internal Exposure Monitoring Program" contains the rationale and criteria for conducting routine thyroid monitoring.
A new Nuclear Data whole body counting system employing a Masse chair and intrinsic germanium detectors was being installed on-site at the time of the inspection.
Two additional whole body counting systems are planned for on-site in vivo monitoring to enhance the program.
The licensee indicated the following matters would be reviewed:
(50-293/86-19-07)
The licensee had established a procedure for in vitro monitoring for internal exposure controls.
However, specific instructions for obtaining fecal samples, and the appropriate analyses for certain isotopes such as transuranics had not been developed at the time of the inspection.
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The establishment of procedures for comparison of air sample results, whole body count data and respiratory protection wo'uld be considered.
- The appropriate guides and standards for determination of intake of radioactive material have not been referenced in procedure. -.
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Radiological Surveillance Program 10.1 Surveillance Program (Radiation and Contamination)
The evaluation of this area consisted of review of procedures, interviews with RP supervisors responsible for its implementation and a review of selected documentation of plant surveys.
The requirements for survey type, location and frequency are specified in matrix form as routine work lists (attachments 1 through 8 to PNPS SI-RP.3001).
RP supervisors make necessary assignments to assure proper frequency of surveys is adhered to.
The work lists are retained as record of surveys.
Individual surveys are documented on survey maps.
Results of surveys are reviewed by RP supervisors and retained for records. Copies of surveys are filed in RWP packages and used to update RWP requirements.
Based on the above, it appears the surveillance program is adequate to ensure proper posting and access control of areas within the plant.
The type and frequency of surveys required are commensurate with the extent of the anticipated hazards to allcw prompt identifi-cation of changes in radiological conditions.
Surveys of personnel and equipment surface contamination rely heavily on " hand frisking" with G-M type pancake probe instruments.
This method is acceptable for detecting contamination.
The licensee has on order a number of high-sensitivity portal monitors.
These will be strategically located.
10.2 Surveillance (Airborne Radioactivity)
The licensee's air sampling program for the control of internal exposure due to airborne radioactive material consisted of high and low volume portable air samplers and limited use of lapel air samplers. The inspector determined that the equipment in use was properly calibrated and appeared to be reasonably well placed at the work location. However, the licensee had not purchased or imple-mented continuous air monitors (CAMS) for detecting and warning of unexpected or high airborne activity. This item was identified in the RIP as item 5.1.la-2 and will remain open as NRC open item 86-02-05.
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20 10.3 Conclusions The routine plant radiation, contamination and airborne radioactivity surveillance program is adequate. However, the program procedures do not provide guidance for modifying the program as a result of changes to the radiological environment (e.g. modification of surveillance program following leaking fuel or high coolant activity).
(50-293/86-19-08)
11. ALARA 11.1 General The ALARA program was reviewed against the criteria provided in Regulatory Guide 8.8 and 8.10 and 10 CFR 20.1.
The evaluation of licensee performance in this area was based on discussions with cognizant personnel, review of procedures, and review of selected work activities.
11.2 Documents Reviewed
Boston Edison Company Policy Statement Number 20, Corporate ALARA Program Nuclear Operations Procedure, ALARA Program, effective date January 3, 1986 Nuclear Operations Department Procedure Number 6.10-013, ALARA Job Reviews, draft date September 24, 1986 Station Instruction, In process Review, PNPS SI-RP.0315, (awaiting approval)
Nuclear Operations Department Procedure Number 6.10-010, ALARA Suggestions, approved January 9, 1986 Station Instruction, Installation and Removal of Temporary i
Shielding, PNPS SI-RP.0400, approved August 30, 1985
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Station Instruction, Engineering Controls Use Criteria, PNPS SI-RP.0205, approved September 23, 1986
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Station Instruction, ALARA Audit, SI-RP.0900, (awaiting
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Station Instruction "ALARA Daily Exposure Review (ADER)", PNPS SI-RP.0100, approved December 11, 1985
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The ALARA program appears in an infancy stage with several areas needing initiation, development, implementation and followup.
Sev-eral procedures for plant design changes, ALARA Cost-Benefit An-alysis, ALARA Committee guidance, Radiation Protection Technician Guidance, ALARA Exposure Budgeting, ALARA Trending, Dose-Reduction Data Sheets, Radiological Protection Tours, and ALARA Goals are in various stages of drafting and review.
11.3 Management Policy and Commitment Policy Statement #20 clearly commits Boston Edison to keeping doses as low as reasonably achievable, and implements the policy through the formal ALARA program described in N0P 83.RCI.
The Radiation Protection Plan reiterates and emphasizes management policy and commitment.
Management commitment to the ALARA program seems good based on evidence of recent approvals for purchases of major pieces of equipment such as two new whole-body counters, several contamination check devices, control rod drive shielding which will cost over a million dollars, and color graphics equipment which is available for production of highly effective trending charts and graphs. Addi-tional management emphasis on section goals and dose budgets, and initiatives (new ideas) for dose reduction by all sections, is needed to further demonstrate that top management considers dose reduction at this plant a priority item.
Management responsibilities and authority are clearly delineated in NOP 83RC1 including management oversight through establishment of an
"ALARA Oversight Committee" to be chaired by the Vice President of Nuclear Operations. This committee's functions were to begin upon dissolution of the radiation protection oversight committee, but not later than March 31, 1986. Meetings were to be held at least quart-
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erly. To date only one meeting of this committee has been held in the absence of its chairman, and minutes of this meeting were not available. Another committee called the "ALARA Committee" consists of nine members with the radiological section head as a chairperson.
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Other members of this committee include chief engineers of various groups and key group leaders.
This committee was to begin not later than December 31, 1985 and meetings were to be held at'least once per month. The first meeting was apparently held August 28, 1986 and a second on September 16, 1986. The number of meetings held by these two committees suggests that the paperwork part of the procedure development has progressed more rapidly than related implementation
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of the procedures, and that top and middle management are not plan-ning for effective ALARA meetings.
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It is important that top and middle level management actively support the ALARA program by seeing that the above committee meetings are held and that their intended purpose is carried out.
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a 1986 station goal of 700 man-rem has been established and dose projections and tracking for individual high-dose jobs is being done, but section goals and outage goals have apparently not been set.
Similarly, although a plant suggestion system was initiated, its cultivation and effective utilization to promote ALARA objectives has not been promoted sufficiently to make it the highly effective program that it must be.
In this regard, discussions with management indicate an interest and intent to make significant improvements in the motivational and attitude development aspects of plant management including incentives for dose reduction and possibly rewards for good suggestions.
The weekly " items of interest" memoranda provide an excellent vehicle for calling management attention to significant problems or events.
Outage reports could be improved with a somewhat more formal struc-ture, for example by including sections on lessons learned, recom-mendations, and an executive summary.
Radiological occurrence reports are being processed routinely.
11.4 Organization and Staffing A defined ALARA Group has been recently established. The position description and functional responsibilities for personnel are docu-mented.
Staffing for the radiological section and ALARA groups seems logical and reasonable for potentially successful implementation of a strong ALARA program.
Filling of the open positions by well qualified in-dividuals will be important to longer term success of the program.
One key position - Senior Radiological Engineer ALARA - is currently
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vacant due to personnel promotion. This position should be filled
on a priority basis to provide oversight and direction to the program.
11.5 Procedures ALARA procedure development is progressing well.
Several excellent procedures have been issued and several oth'ers are well'along in development.
However, as noted above, procedure implementation is not always complete.
Procedure implementation must be followed carefully to ensure that the intended benefits of each procedure are -
obtained.
It is also important that any difficulties encountered in implementation be addressed early.
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Based on the large number of procedures that have been developed within the past few months, the number currently being developed, and the quality of the material contained in these procedures, it appears that the health physics staff is making a sincere effort and progress in these areas.
11.6 On-going Activity Review Pre-job planning and dose budgeting and tracking for high dose jobs (expected dose greater than 10 man-rem or if an exposure rate in excess of 5 r/hr to the whole body or 10 R/hr to the extremities) are being pursued effectively using the "ALARA Daily Exposure Review".
ALARA trending activities are good and are providing important data for tracking deses, RWP usage, RORs, etc. The draft station instruction on trending when fully implemented should serve to provide the mechanisms for effective utilization of the trending data.
11.7 Conclusion The radiological section seems to be making good progress in devel-oping the ALARA program. However, additional initiatives for dose reduction are needed from all sections.
Each section should iden-tify areas and activities of possible dose reduction and make pre-liminary estimates of g 231ble dose saving; and costs to provide a basis for future decisions. A comprehensive evaluation and priori-tization of numerous possible dose reduction actions is needed to focus attention on specific nrads as well as stimulate additional thinking about ALARA.
The ALARA program contains the following weaknesses:
(50-293/86-19-09)
Need for improving inter and intra - departmental working relationships and communication, Lack of effective meetings by the ALARA Oversight Committee, and too few meetings by the ALARA Committee.
- Need for challenging section goals and additional initiatives for dose reduction, and vigorous program followup and imple-
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Need for complete development and/or implementation of procedures.
12.
Radioactive and Contaminated Material Control 12.1 General The adequacy and effectiveness of Radioactive and Contaminated Material Control was reviewed. Specific areas reviewed were as follows:
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Implementation and Adequacy of Improvement Item as described in Boston Edison Radiological Improvement Plan, Chapter 12, Radioactive material Controls.
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Posting, L'abeling and Control of Radioactive and Contaminated
Material.
12.2 Documents Reviewed Boston Edison Radiation Protection Plan
Procedure No. 6.1-211, Radiological Release of Vehicles /
Materials to Offsite.
Procedure No. 6.9-197, Operation and Control of Radioactive Material Storage Areas.
12.3 Findings The Radioactive and Contaminated Material Control Program is de-scribed in the Radiation Protection Plan.
Implementing procedures for onsite control and offsite re' ease of materials are established and implemented.
Significant improvement in the in plant control of materials has been made. Identified weaknesses in procedures for offsite release of materials have been corrected through revision to procedures.
The facility exhibits a large number of contaminated areas thus necessitating an aggressive contamination control program. The licensee has established a decontamination plan to decontaminate, by March 1987, all critical safeguards areas to allow access in street clothes.
Dart of the planning process is to develop a decontamina-tion plan, with milestones for the entire station.
Procedures for storage and control of radioactive and contaminated material have been substantially improved. All storage locations are pre-designated and approved.
Flow into and out of major storage locations is tracked by computer. A dedicated radioactive material control supervisor oversees storage and control of, radioactive or contaminated material.
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The reviews of this area indicated the licensee has substantially improved his oversight and control of radioactive and coot minated material.
Instances of improper storage, spillage or identification of unexpected contamination of normally non-contaminated areas are addressed via the radiological occurrence report system.
Despite these improvements, weaknesses in some aspects of the program were identified. The licensee indicatad the following matters would be reviewed: (50-293/86-19-10)
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An unapprovecj, unreviewed? instruction is being used by main-tenance personnel to provide guidance for decontamination and storage of contaminated tools.
Licensee personnel indicated the
' ll instruction will be reviewed and its information will be incorporated into> the Radioactive and Contaminated Material Control Progran.
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The current radioactive and contaminated material storage pro-gram does noticontain adequate provisions to ensure that the types and quantities of material stored comply with the.limita-
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tions imposed'iby applicable safety evaluations.
Licensee per-sonnel indicated that' provisions would be included in applicable procedures to ensure that the types and quantities of material stored are within applicable safety evaluations.
It is not apparent that procedures for establishment of new radioactive and conta,tinated material storage areas provide for all applicable safety reviews (e.g. seismic loading, fire
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protection) prior to establishment of the area.
Licensee personnel indicated the procedures for establishment of new storage"iocations would be reviewed'to ensure that all
applicable reviews are performed' consistent with NRC guidance (e.g. Generic Letter 81-38).
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' All procedures for receipt of radioactive material did not
,g ensure that appropriate surveys required by 10 CFR 20 would be
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performed within the time constraints specified therein..
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Licensee personnel indicated security procedures would be
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revised to ensure radiation protection personnel are notified
, of receipt of radioactive mater,ial in a timely fashion to allow them to perform package surveys within 10 CFR 20 time con-straints.
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Procedures for release of material offsite do not discuss loose or fixed alpha contamination, surveys of inaccessible areas,
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types of alternative surveys for "non-routine" material released (e.g. soil) offsite; or lower limits of detection for this non-routine material.
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Procedures for " direct frisk" of material co not take into consideration' mixtures of beta gamma nuclides and counting efficiencies' to be realized for variations in mixtures.
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- Procedures for counting alpha contamination smears do not-address self-absorption corrections.
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13.
Facilities and Equipment 13.1 Instrument Calibration Laboratory The calibration laboratory is used to calibrate survey instruments and self reading dosimeters.
The organization, procedures and equip-ment pertaining to the laboratory were found to be generally sound with certain exceptions in the area of calibration sources and their use. Most instrument calibrations are performed using one of two gamma ray calibration sources: a well type, high activity calibrator and a low activity open calibrator. Although the well calibrator can produce fields of up to approximately 230 R/hr, higher fields may be needed for calibration of the high range instruments.
Currently, the well calibrator is being calibrated using a condenser R-meter. How-ever, because of the high contribution by scattered radiation in this type of calibrator, this calibration may not be accurate. Also, the response of different types of instruments to a given exposure rate may vary because of their different responses to the scattered component of the radiation field inside the calibrator.
Consideration should therefore be given to upgrading the well and the open sources to higher activities. The current practice of standing close to the edge of the irradiation cone of the open source during calibration to observe the instrument readings is not good ALARA practice.
The following areas were considered minimally acceptable.
However, the licensee indicated that they will be reviewed for possible improvement:
(50-293/86-19-11)
Adequacy of the activities of the well and open calibrators to cover the full range of instrument calibrations.
- Adequacy of the method of using the well calibrator to calibrate instruments considering scattered radiation.
- Adequacy of the calibration facility, or room, to house higher activity sources if the current sources are upgraded.
13.2 Health Physics Counting Laboratory The organization, staffing, and equipment in the counting laboratory were reviewed and some weaknesses were identified, mainly in the area of quality assurance / quality control, QA/QC. Although QC procedures are available and appear to be adequate, they are being implemented in a less than adequate manner. The QA/QC data is not being carefully and meaningfully pictted on the control charts and the data is not being reviewed. Hardware appeared to be adequate
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under the conditions prevailing during the inspection, which took place during the preparation phase of an outage.
Two high resolution gamma spectrometers have recently been installed and should be suf-ficient for most anticipated situations.
The number of counting systems also appeared to be adequate, although consideration should be given to increasing their number to provide for backup capacity for extra heavy demand or in cases of breakdowns or contamination of the counter.
The inspector stated that there did not appear to be any formal document or manual that discussed the technical bases for some of the counting room operations.
Particularly, MDA and LLD were apparently both being used by the laboratory but it was not clear how or under what circumstances each was used. Also, the limits on the control charts were apparently not being established in accordance with any specific action levels based on desired or required sensi-tivities, accuracies, or LLDs.
The following areas were considered minimally acceptable.
However, the licensee indicated that they will be reviewed for possible improvement:
(50-293/86-19-12)
Improvements in current QA/QC practiced.
Improvements in supervisory review of counting laboratory data, particularly daily QA data.
Need for additional counting equipment.
- Development cr' a technical bases manual or document to record the technical bases for certain practices, such as for example the choice of quality control chart limits, methods of calcu-lating LLD or MDA, specification of the conditions under which the LLD and MDA are used, and so on.
14.
Exit Meeting The inspectors met with licensee representatives (denoted in Section 2)
at the conclusion of the inspection on October 24, 1986.
The Team Leader summarized the performance scope and findings of the inspection. At no time during the inspection was any written material provided to the licensee by the inspector.