IR 05000312/1986006
| ML20202H012 | |
| Person / Time | |
|---|---|
| Site: | Rancho Seco |
| Issue date: | 03/26/1986 |
| From: | Cillis M, Prendergast K, Yuhas G NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| Shared Package | |
| ML20202G987 | List: |
| References | |
| 50-312-86-06, 50-312-86-6, NUDOCS 8604150062 | |
| Download: ML20202H012 (20) | |
Text
,
.
,
_.
.
U. S. NUCLEAR REGULATORY COMMISSION
REGION V
Report No.
50-312/86-06 Docket No.
50-312 License No.
DPR-54 Licensee:
Sacramento Municipal Utility District P. O. Box 15830 Sacramento, California 95813 Facility Name:
Rancho Seco Nuclear Generating Station Inspection at:
Clay Station, California Inspection conducted:
January 21-24 - February 3 and 6, 1986
- L hebd 2/2f/f6 Inspectors:
K. Prendergdst. Emethency Preparedness Analyst DWre' Signed
YW het 3/36}R$
M. Cill Radiati(n) Specialist Ddte Signed Approved By: MhNh Q/34/17f
,
G. YuhQ,\\ Chief-D' ate Sigt.ed
~
Facilities)Radiolog'. cal Protection Section Summary:
,
Inspection on January 16-24~ -February 3 and 6, 1986 (Report No. 50-312/86-06)
Areas Inspected: Unknnounced special inspection by two regionally based NRC inspectors of the licensee's emergency plan implementation and radiological control practices during f.e December.26, 1985 plant transient. During this inspection,-Inspection Procedure's 93702,-82203 and 83726 were accomplished.
Results: Of the two areas inspected, apparent. violations involving the failure to establish, implement, and maintain procedures as required by Technical Specifications 6.8 (see paragraphs 4 and 5) were identified.
<
8604150062 860328
{DR ADOCK 05000312 PDR
.
-
. -
-
-
-
.
-
-
. -
- -.
.
{
'
i
.
l l
DETAILS j
1.
Persons Contacted A., Licensee Personnel
!
- +G.' Coward,'Manbger, Nuclear' Plant
- +J. McColligan, Assistant Manager, Nuclear Plant l
- +S. Redeker,-Manager, Nuclear Operations l
'F. Kellie, Radiation Protection Manager
- +J.
Jewett, Site QA Supervisor
,
l
-+R.' Dieterich," Manager, Licensing
- +S.. Crunk, Supervisor, Incident Analysis Group (IAG)
- +R. Colombo, Regulatory Compliance Supervisor
+R. Meyers, Supervisor, Emergency Preparedness S. Woods, Shift: Supervisor A.'Jennings, Auxiliary Operator (AO)
l M. Peterson, Equipment Attendant (EA)
'
W. Partridge, Chemistry Radiation Assistant (CRA)
G. Pederson, CRA
+E. Bradley, Supervising Health Physicist
- +J. Rcese, Plant Health Physicist
+H. L. Canter, Quality Assurance Operations Surveillance Supervisor
+R. Rochler, Licensing Engineer
+B. Thomas, Public Information Specialist
+K.
Shearer, Public Information Specialist
+W. E. Helums. Emergency Planning Specialist
+N. Brock, I&C Maintenance Superintendent
- +J. Field, Technical Support Superintendent R. Thomas, Senior Nuclear Operations Engineer
+W. Spencer, Nuclear Operations Superintendent
+D. Marsh, QA-HP Engineer G. Simmons, Shift Technical Advisor (STA)
I B.
Non-Licensee Personnel - Impell Corporation
- +P.
Lavely, Health Physicist C.
Offsite Agency Officials l
l l
B. Tong, State Office of Emergency Services S. Crowder, Amador County, Office of Emergency Services
[
D.
Nuclear Regulatory Commission (NRC)
r
- +G. Perez, Acting Senior Resident Inspector
- Denotes attendance at exit interview conducted on January 24, 1986.
l
.
+ Denotes attendanca at exit interview conducted on February 6, 1986.
In addition to the individuals identified above, the inspectors met with contractors and other members of the licensee's staff.
l l
)
J L
.
i.
-
,,
,,
,
.
i' *
'
h.
,,
.
_,
q
.
-
<
,
c,
,
"
' /
'
) ~ 2
,
.,t
_.
m
,
'
2.
Background On December 26, 1985, Rancho Seco experienced a loss of integrated control system power which lead to an over cooling transient. NRC implemented the Incident Investigation Team (IIT) and published the results of their. review in NUREG-1195. As a result of the preliminary IIT findings, Region V conducted a special inspection to review the licensee's implementation of their Emergency Plan and radiological control program.
The plant transient resulted in the declaration of an " Unusual Event";
an unplanned release of about 33 Curies of gaseous radioactive material; a v.edical emergency; contamination of several workers, and failure of equipment having radiological significance.
3.
Scope Specific areas reviewed during this inspection included:
Implementation of the Emergency Plan (EP) and the Emergency Plan Implementing Procedures (EPIPs).
- Classification of the Event.
- Notifications
,
EP/EPIP Training
Staffing
Implementation of the licensee's Radiation Protection Manual during
]
~ the Unusual Event.
Evaluation of the radioactive release.
Utilization of the Control Room / Technical Support Center (CR/TSC)
HVAC cleanup system.
- Performance of the Process Effluent Radiation Monitors, R15001, R15002, R15044 and R15045 during the event.
The inspection consisted of discussions with the licensee's staff on shift at the time of the event, discussions with representatives of offsite agencies,'and a review of the following procedures, documents,
,
logs and records
Emergency Plan sections;
- 2.0, " Scope and Applicability"
- 3.0, " Summary"
- 5.0, " Organizational Control"
- 6.0, " Emergency Measures"
'
,,
- 8.0, " Maintaining Emergency Preparedness"
'
'.
e
b
%
% *
..y /
f
,f.
. '
,.
.
<,
-.
.
~
.
Emergency Plan Implementing Procedures;
- AP 501, " Recognition and Classification of Emergencies"
- AP 502, " Notification of Unusual Event"
- AP 506, " Notification / Communication"
- AP 506.01, " Activation and Operation of the Technical Support Center"
- AP 507, "Onsite Radiological Monitoring"
- AP 509, " Control Room Dose Calculations"
- AP 511 " Technical Support Center Dose Calculations"
- AP 514, " Personnel Injury"
Radiation Protection Manual Procedures;
- AP 305, " Radiation Control Manual"
- AP 305-4, " Radiation Work Permits"
- AP 305-9B, " Personnel Contamination Monitoring"
- AP 305-20, "Whole Body Counting"
- AP 305-24, " Reactor Building Air and Stack Samples"
- AP 305-26, " Auxiliary' Building Air and Stack Samples"
- AP 305-28, "MPC Determination at Site Boundary from Radioactive Releases"
- H2PSA-7, Annunciator Response Procedure; Window Number 12,
" Gas Radiation Monitor"
Training Records
Technical Specifications (TS)
Control Room Log
Shift Supervisors (SS) Log
Chemical / Radiation Logs (Hot and Cold Lab)
Licensee's Personnel Interview Log Sheets related to this event
Radiation and Contamination Surveys
Whole Body Counting Records
Radiation Protection Managers Evaluation of this Event
Offsite Dose Calculation Manual (ODCM)
4.
Emergency Plan Findings a.
Staffing Prior to this event, shift manning was consistent with TS 6.2-1 and Emergency Plan Section 5.28t"
.Although the minimum staffing requirements were met, the licensee was short four individuals from:the normal crew complement (one control. operator, two auxiliary operators and one equipment attendant).
.
While no v'iolations'o5 deviations were identified, the overall adequacy of staffing will'be addressed in response to the IIT findings..
..
...
'
m
,
,
+
y g
'
.
I
..
.
.
-.-
-
-
- i
b.
Training The Control Room staff on shift had received the annual EP retraining on November 27, 1985. This training consisted of about a two-hour reading of a packet containing selections from.the EP and EPIPs followed by a discussion session and a written test. Of the five control room staff interviewed, the Shift Supervisor (SS),
Senior Reactor Operator (SRO) and two Auxiliary Operators (A0s)
characterized this training session as " terrible". One Equipment Attendant (EA) felt the training was good but contained more information than he could use. The licensee's implementation of the Emergency Plan and radiation control program as described in this report also indicates inadequacies in the training program.
The licensee's evaluation of training and corrective actions will be reviewed in a subsequent inspection.
(50-312/86-06-01)
c.
Classification of the Event According to the onshift crew the event was classified pursuant to AP 501, " Recognition and Classification of Emergencies," Tab 8, Notification of Unusual Event (NOUE) " Abnormal Reactor Coolant Temperature or Pressure", at 4:30 a.m. December 26, 1985.
The review indicates the licensee properly classified the event.
The inspectors noted that during the course of the event it could also have been classified as a NOUE pursuant to Tab 4, "High Effluent Activity", Tab 6, " Emergency Core Cooling System (ECCS)
Initiation", and Tab 9. " Secondary Depressurization". However, at no time did the event warrant classification as an " Alert" under any criteria.
l The inspector noted that in Tab 6 of AP 501 the " initiating
'
condition" conflicts with the " Emergency Action Level" in that the
" initiating condition" refers to an actual ECCS initiation where as the " Emergency Action Level" refers to an inadvertent safety features actuation.
This inconsistency was brought to the licensees attention during the exit interview.
Noviolati$nsordeviationswereidentified.
d.
Notifications
s EPIP AP 502, " Notification of an Unusual Event", Revision No. 5, dated December 2, :1985 is the procedure which describes' the actions to be taken in the event a Notification of Unusual Event has been declared. This section of the report documents the licensee's implementation of AP 502.
According to the control room staff, the Shift Supervisor assumed the role of Emergency Coordinator (EC) and announced this to the control room staff. He opened and reviewed AP 502. He directed the
,
.
.
Senior Control Operator (SCO) to fill the roles of Technical Report Coordinator and Communicator, pursuant to step 5.1.5 of AP 502.
1)
AP 502, step 5.1.3 requires the EC to:
" Direct the emergency alarm be sounded for ten seconds, and announce or have announced the following message over the public address system:
" NOTE:
If other than an actual event, precede the announcement with "This is a Drill" or "This is an Exercise", as appropriate.
Also, if appropriate, include in the announcement any PRECAUTIONS to be followed in order to ENHANCE the level of PERSONNEL SAFETY.
ANNOUNCEMENT:
" ATTENTION ALL PERSONNEL, ATTENTION ALL PERSONNEL: AN UNUSUAL EVENT HAS BEEN DECLARED. ALL PERSONNEL CONTINUE WITH THEIR NORMAL DUTIES UNTIL FURTHER NOTICE."
(Repeat the alarm and announcement)."
This announcement was not made. The EC stated that he forgot to make the announcement.
The two on-shift Cheristry Radiation Assistants (CRAs) were not informed that an Unusual Event had been declared. The Shift Supervisor had informed one of the CRAs at about 4:15 a.m.,
that the reactor had tripped and requested he take a reactor coolant sample.
Because this announcement was not made, it appears chemistry and radiation protecti.on personnel were not informed of the problems in the plant and other personnel in the plant were not made aware'of'what safety precautions to take.
In addition, it appears that one individual was contaminated because he was unaware of plant conditions.
This represents an example of failure to implement a procedure.
2)
AP 502 Step 5.1.8 states:
" Implement AP 506 " Notification / Communications":
Complete the offsite agency Initial Notification a.
Form, Attachment 7.1.
,
b.
Direct the Communicator to initiate the Emergency Notification Call List, Attachment 7.2.
Initiate the NRC Notification Form Attachment 7.3."
c.
t
-
.
...
6-AP 506 Step 4.2 states:
" Notification shall be made within 15 minutes of the declaration of the emergency classification to the following governmental agencies:...."
The Communicator notified the required governmental agencies at about 4:30 a.m.
The notification included:
Ihat an Unusual Event had been declared; a loss of integrated control power caused the reactor to trip; and that an excessive cooldown was in progress. The Communicator said that they would call back with more information.
Attachment 7.1 of AP 506.had been developed and approved in
_
conjunction with the responsible offsite government agencies specifically, the counties of Sacramento, San Joaquin and Amador and the State of California.
This attachment was designed for use by the licensee and governmental agencies to assure that the pre-arranged information is transmitted and documented by both parties. This is accomplished in order to assure that all governmental agencies responsible for protecting the public receive enough information to formulate protective actions for their constituents.
The licensee's completed version of Attachment 7.1 was reviewed.
Item 8 (Wind direction and Speed), Item 9 (Downwind Sectors Affected) and " Approval time" were not completed.
The governmental agencies. stated that the initial notification to them did not include the following items: (2) this is an actual emergency, (5) offsite radiological release status, (6)
considerationLof'public protective actions, (7) Emergency Operations Facility (EOF) activation, (8) and (9) as above and (10) initiating condition: " Tab Number".
.The' governmental agencies. expressed concern that they could not properly implement their' decision making process since the initial report failed to'contain all the previously agreed to information.
Specifically, the " Tab Number" is considered fundamental to the local governments ability to understand the initiatin~g event. The failure to provide the offsite agencies
,
with adequate information of the event and to provide reasonable updates of plant events (as described later in this report) could have led to a delay in the counties taking protective actions, should protective actions been necessary.
Although the counties received no follow-up notification, the State of California received a high stack radioactivity alarm from Rancho Seco at 5:04 a.m.
At 5:21 a.m.,'the State of California called Rancho Seco to question the status of the high stack radioactivity alarm. The
+
.
xt,
,':;
>: x 41 - % *
, _,.
-t;,!'
c,
- j
-
,
,
.:
'
,s.
[
> ]. !v, '
' '
'
'"
>x g
.x
-
,~
n
, -
,
EC advised the State that this alarm was caused by failure of the makeup pump which resulted in reactor coolant leaking into-the makeup pump room. The pump was being isolated and-
-chemistry people' vere checking it out.
The stack alarm was
~
reset during this conversation.
Failure to make the announcement over the plant public address system required by Step 5.1.3 of AP 502 and to provide local governmental agencies complete initial notification information is sufficiently important to be considered an apparent violation of Technical Specification 6.8.1(e)
(50-312/86-06-02).
3)
AP 502, Step 5.1.6 states:
" Implement Emergency Coordinator's log keeping per AP 501, Attachment 7.4."
AP 501, " Recognition and Classification of Emergencies" section 5.3 states:
"During the course of'the emergency, maintain Attachment 7.4, Emergency Coordinator's Emergency Log.
5.3.1 As the Emergency Coordinator's position is assumed or relieved. the off-going Emergency
.
Coordinator shall log, " Relieved by (name). The on-coming Emergency Coordinator logs, " Relieved the' Emergency Coordinator.
5.3.2 Record emergency response actions initiated, Emergency Plan Procedures implemented, and a chronology of significant events related to the emergency.
5.3.3 Record description of the emergency _
communications sent and received.
5.3.4 Record changes in Emergency Classification or-plant status."
A specific Erergency Coordinator's log was not established pursuant to' Attachment 7.4.
The Emergency Coordinator stated
that this action was not performed since he focused his efforts-on mitigating the plant transient.
In his opinion,'the
->
information requested should have been captured by the Technical Report Coordinator. Review of the control room log ~
maintained by the Technical Report. Coordinator and the Shift Supervisors log indicates the desired information with exception of emergency communications sent and received
, appeared to have been documented..
Failure to establish,a spebific EC log represents an example of
. ' ', failure to. implement a procedure.
'
,
.
,
,
,,
,
,
g J,
'
[
.
't
y
..,,
'
'%
'
i,
' < '
,j
,
3- _
,
-
._
. -.
.
t l
- 4)
AP 506, Step 5.1.4 states'the Emergency Coordinator shall:
!
" Complete or direct the Communicator to complete, Attachment 7.4, Follow-up Notification Form, Form B, as emergency / plant conditions change and instructs the Communicator to transmit the information to local and state organizations (Attachment 7.2, page 2 (3)).
!
-NOTE: Follow-up information should be sent to the state and counties at least hourly during the emergency."
According to plant staff, Attachment 7.4 was not filled out l
during the event. The staff indicated they were too busy to complate the attachment because of plant priorities. Officials I
from Sacramento, Amador, and San Juaquin counties stated they-were not updated by Rancho Seco until the termination of the event at 8:41 a.m.
The only updates made by the licensee were to the State of California and to the NRC. The update to the State was made at 7:00 a.m.
Failure to make the followup.
l notification to the local governmental agencies as required by step 5.1.4 of AP 506, is sufficiently important to be considered an apparent violation of Technical Specification 6.8.1.e (50-312/86-06-03).
5)
AP 506, Step 5.1.2 requires the EC'to:
Direct the Communicator to initiate Attachment 7.2,
" Emergency Notification Call-List," providing emergency response organizations and SMUD personnel with the l
information recorded on Form A.":
i The assigned communicator stated that the notifications
'
identified in Attachment 7.2 were made but not documented because plant priorities required their full' attention.
6)
AP 502, Step 5.2.1 requires the EC:
" Consider the augmentation of additional personnel.
If l
necessary, direct the Site Switchboard Operator to make
the notifications."-
'
,
At about 4:25 a.m., the Emergency Coordinator determined that the shift staff needed augmentation. He directed the Shift j
Technical Advisor (STA) to call'in the oncoming shift. The STA did not have time to call in,the oncoming shif t until about
,
5:00 a.m.. due.to;his efforts to mitigate the plant transient.
.
The STA stated that he.did'not consider requesting the Site t
l Switchboardioperator to'make the notifications since he was
!
' aware the operator did not have a list of the oncoming shift
-
'
crew.
,
,
.
,
l
'
'
'Y r
's
.
!
.
o'
.
}
.,
h.,
+
s a
'?
,
,
t
- I
l;
,
S-
=
,
i f.
"
s
,
<
,,
m.
..-
.
..
.
m_. _ _ _____. _ _ _. _ _. _ _ _ _ _ _, _ _ _. _ _ _ _ _ _. _. _. - _ _ _ _ _. _ _ _ _ _.
m
.
.
..
.
um
.
.m
. m
-
.
'
7)
AP 506 Step 5.1.3 states the Emergency Coordinator:
" Completes Attachment 7.3, "NRC Notification Form," Part I and Part II (for reporting the occurrence of a significant event'in accordance with 10 CFR 50.72), and instructs the Communicator to transmit the information to the NRC."
The Communicator using the Emergency Notification System (ENS)
informea the NRC Headquarters Operations Officer at 4:42 a.m.
of the event. However, attachment 7.3 was not filled out or I
maintained during this event.
The Emergency Coordinator stated that he did not complete Attachment 7.3 due to his efforts to control the plant.
i The Communicator stated he located a blank copy of Attachment 7.3 and used it as a guide to provide information to the NRC.
This represents an example of failure to implement a procedure.
8)
AP 502 Section 5.1.9 requires the EC to direct the communicator to notify District Personnel listed in Attachment 7.1.
No records of Attachment 7.1 could be produced by the licensee.
The inspector observed that neither AP 502 Attachment 7.1 or AP 506 Attachment 7.2, included a representative from the radiation protection and chemistry organizations.
All of the above observations were brought to the licensee's attention at the exit ir.terview.
e.
Emergency Plan Implementing Procedures 1)
AP 502 Step 5.1.10 states ~
"If, at the Emergency Coordinator's discretion, Technical Support Center (TSC) activation is warranted, implement
' AP 506.01."
"
The Shift Supervisor's Log states at 6:44 a.m.,
the TSC was
!
, manned. Discussions with the Emergency Coordinator indicate
'
that partial activation of the TSC was accomplished to augment plant resources,but AP 506.01 was not implemented.
Since the TSC,was.not required to be manned at the l
'
classification of an Unbsual Event, no apparent violations were identified.
2)
AP 502 Section 5.2, " Subsequent Actions," states in Step 5.2.2
" Implement additional Emergency Plan Procedures as necessary."
.
-
,
Following failure of the makeup pump, the Auxiliary Building Vent Monitor R15002B alarmed at about 5:00 a.m.
R15002B was set to alarm at 60,000 counts per minute (cpm) on July 21, 1984, which is consistent with the methodology presented in the licensee's Offsite Dose Calculation Manual (ODCM). The alarm setpoint is based on not exceeding the instantaneous noble gas release rate, which would result in a dose rate of 500 mrem / year at the site boundary due to simultaneous releases from the containment building and auxiliary building vents.
AP 501, Tab 4, "High Effluent Activity," lists the alarm set point for the auxiliary building stack gas monitor, R15002B, as 20,000 cpm. Licensee memorandum dated August 3, 1984, February 26, 1985 and March 21, 1985, all indicate the licensee was aware of the need to update the radiation alarm setpoints in the EPIPs. This and other radiation monitor setpoints were not corrected during the December 1985 revision of AP 501.
AP 501 does not address the utilization of radiation monitors R15045 (High Range Gas), R15049 (In Containment High Range Monitor) or R15050 (In Containment High Range Monitor) for classifying an event. These monitors were installed for the purpose of meeting the guidance contained in NUREG-0737,
" Clarification of TMI Action Plan Requirements". These monitors are not utilized in AP 509, AP 511 or AP 512. This matter was brought to the licensee's attention during the exit interview.
In addition, it was noted that the EPIPs provide no method to project offsite doses resulting from scurces originating from a primary to secondary leakage pathway. The licensee was aware of this deficiency and plans to correct the matter.
Failure to maintain EPIP AP 501 current with changes in the radiation monitor alarm setpoints is sufficiently important to
'be considered an apparent violation of Technical Specification
'
6.8.1.e (50-312/86-06-04).
3)
AP 514, " Personal Injury,"' describes the action to be taken in response to a personnel injury onsite. At about 4:52 a.m., the
" backup" Shift Supervisor collapsed in the control room. The Emergency Coordinator assessed the individual's condition and had an ambulance called at 5:07 a.m.
The Galt ambulance arrived onsite at about 5:36 a.m., and transported the individual to Methodist Hospital.
No violations were identified in the execution of this procedure.
5.
Radiological Controls Findings The licensee's radiological control requirements for normal plant operations and emergencies are included in their Radiation Control Manual and Emergency Plan,
-
-
-
- - -
-
- -
-
- -
.
'
a.
Staff and Qualifications Two individuals from the licensee's Chemistry and Radiation Protection organization were on shift at the time of the event.
This is consistent with the staffing requirements of Technical Specifications, Section 6.2.2.
One of the individuals, a Chemistry Radiation Assistant (CRA), was qualified ia radiation protection and chemistry procedures, while the second indisidual who is also a CRA was qualified in chemistry and was partially qualified in radiation protection procedures.
No violations or deviations were identified.
b.
Radioactive Effluent Release When the makeup pump failed at about 4:45 a.m., dissolved and entrained noble gases were released from the liquid spilling onto the makeup pump cubical floor. This resulted in localized high airborne radioactive gaseous activity which was purged from the auxiliary building through high efficiency particulate and charcot1 filters and discharged to the environment via the auxiliary building stack. This stack is monitored by normal auxiliary building vent monitor (R15002B) and the wide range gas monitor (R15045) for
'
radioactive gaseous activity.
An evaluation of the licensee's assessment of the radioactive releases was made to determine compliance with 10 CFR 50.72, 10 CFR 50.73 and Technical Specifications, Section 3.18.1.
The evaluation disclosed the following:
The effluent release resulting from the makeup pump failure caused the auxiliary building vent monitor to alarm.
'
,
!
The total curies of noble gases released during the entire l
transient were initially estimated at 80 curies, subsequent reevaluation.by the licensee determined the actual activity released was:-
,
a)
Xe-133 30.4 ' Curies b)
Xe-135 1.97 Curies c)
Kr-85m 0.33 Curies The licensee also reported to the NRC on the Emergency Notification System (ENS) that the site boundary Maximum Permissible Concentration (MPC) determination made at approximately 5:15 a.m. was calculated as 0.93 MPC from the
,
l highest release rate which took place for approximately l
ten minutes. The site boundary MPC at 6:50 a.m. was determined to be 0.054 MPC. Both values are below'the reporting requirements prescribed in 10 CFR Part 50.72.
l Annunciator Response Procedure H2PSA-7, Window 12 (which
j includes R15002B)
Step #2 states: " Evacuate personnel from
!
l L
s-
,
~
,
.
,
,
-
.
'
'
(
,
-
!
area being monitored for high activity gas." and Step #4 states: " Notify Chem / Rad or emergency team to don respirators and make reentry into area to obtain air sample and determine source of high' activity in accordance with the Emergency Plan."
i R150028 slightly exceeded it's alarm setpoint of 60,000 cpm at about 5:05 a.m.
The Emergency Coordinator did not evacuate the auxiliary building, direct respirator's be donned, or direct that reentry be made to collect air samples.
This represents an apparent failure to follow procedures.
Annunciator response procedure H2PSA-7, Window 12, states that
the alarm setpoints for the containment building and auxiliary bui311ng stack monitors R15001B and R15002B, respectively are set at approximately 45% of TS limits for instantaneous release of Xa-133. This statement is not consistent with the actual setting of the instrument as described in the Offsite Dose Calculation Manual (ODCM).
This represents an apparent failure to maintain procedures i
current.
l l
Annuciator response procedure H2PSA-7 does not include
instructions for responding to the wide range gas radiation monitor R15045 which was installed pursuant to NUREG-0737,
Item II.F.1.
Radiation monitor R15045 serves as a backup to the auxiliary building stack monitor, R15002.
"
l
Radiation monitors R15002B and R15045 both alarmed during the event. The setpoints for the two monitors did not agree with one another. The setpoint for R15002B differed by an approximate factor of ten higher than the R15045 monitor.
Although both instruments monitor the auxiliary building stack there is no specific criteria for the alarm setting for R15045.
The difference in alarm set points represents a potential source of confusion.
The licensee was aware of this inconsistency.
- Procedure AP 507, "Onsite Radiological Monitoring," developed
for implementing onsite radiological controls during an j
'
emergency includes the following initiating conditions:
'
"Inplant survey data is needed to estimate or verify source term, or Evaluate areas containing equipment requiring adjustment or repair, or
Evaluate habitability for recovery work, or
,
l Onsite survey data istneeded to verify source term n
estimates or document site boundary levels, or
]
.
i
f
+
g
..
,
-..
.
.
....
__
.
.
,
c
-.-,;
,.g?
-
,
.,s
,
,
,
,
,
N-713 l
l Survey data is required to evaluate Emergency' Response.
l,,
Facilities. habitability."
,
~
l This procedure was not initiated by the Emergency Coordinator.-
,
Tae Emergency Coordinator stated he elected-not to implement i
j
.this procedure because of the short duration of the alarm.
!
'
,
.
.
!
' Procedure AP 509, " Control Room Dose Calculations," states that
-
the Emergency Coordinator ~is responsible for implementing this procedure and then comparing'the results to the protective
,
action guides'per AP 528. The procedure is used to determine
.
l the radioactivity releaseLrates.and for projecting the whole body and thyroid inhalation dose rates at the site boundary.
'
This procedure was not initiated by the Emergency Coordinator (EC) during this event. -The EC assumed that the onsite CRAs were qualified to perform this function; however, the
,.
inspection revealed that the CRAs were not trained to perform this function.
n Portions of procedure AP 511. " Technical Support Center Dose
Calculation," were partially implemented by the Radiation Protection Manager upon his arrival at the site at approximately 7:00 a.m. on December 26.
,
The Emergency Coordinator stated that he requested the CRA to
perform an MFC determination at the site boundary on receipt of the R15002B alarm. The onsite CRA informed the inspector that he was unable to find'a procedure for making the determination (AP-305-28, "MPC Determination at Site Boundary for' Radioactive
~
Releases"). The CRA was unaware that this procedure was available in the licensee's Radiation Control. Manual.
'
~
Procedure AP 305-28, paragraph 3.1.1-requires the evaluation be accomplished in the following manner:
,
"a.
Sample the stack for noble gases, tritium, particulate, ar.d charcoal (iodine).
I b..
As soonfas possible, perform the evaluation based on'neble gases.oCo11ect tritium, particulate, and charcoal l
.
(iodine);. sample for one hour.
l
.
(
.
~
.
.
'
!
-
c.-
If the release. changes,-additional noble gas samples _will-
",r-be required'in order to average over one hour.
'
.
,
+
-
.
s
,
...
.d.,, Determine Con. centration at Site Boundary."
t.
,
,.
,
I i
LThe CRA" failed to sample the stack as required by the.
'
s
<. procedure.C..The CRA did-perform a reasonable MFC site boundary
,;
determination by using the data obtained from the wide range
!
i, gas'acnitor R15045 and his' previous. training ~1n-this area.:
i a
,a e
+
-
,
, _.,
,,
iThis represents anfexample of/ failure to implement a procedure.
'
.
-
3;
...
.
~w#
U
.
r g >
.
-
-,.
,,
.
..
-
,.,.
Y j
$
r
,s
-
.
,
+I s
,
.
d y
/
.
.
"
A subsequent sample taken about 8:00 a.m. indicated that no
detectable radioactive iodine or particulate activity had been released during the transient.
A printout of radiation monitor R15045 data indicated the
maximum release occurred at 5:05 a.m.
A value of 1.63 E-3 uCi/cc was measured. Readings of 1.34 E-3 uCi/cc were also measured at 6:22 a.m.
The auxiliary building ventilation system tripped at
approximately 5:36 a.m. and was restarted at about 6:16 a.m.
The Radiation Protection Manager indicated that the increased release levels observed at 6:22 a.m. were probably associated
,
with the restarting of the auxiliary building ventilation system.
The projected annual whole body dose to a person at the highest
downwind site boundary sector was calculated by the licensee for the purpose of determining compliance with Technical-Specifications, Section 3.18.1(a). The initial assessment made by the licensee was extremely conservative. A reassessment using more precise techniques was made by'the licensee on-February 7, 1986, found that the highest hourly site boundary instantaneous dose rate was 46 percent of the Technical Specification limit.
The dose rate at the exclusion area boundary was determined to be 0.06 mrem /hr. The mtximum affected site boundary whole body dose for this' event was determined to be 0.02 mrem. The maximum whole body dose for this event at the exclusion area boundary was determined to be 0.034 mrem.
,
The, examination disclosed the radioactive release did not result in
,
a significant threat to the environment, to the public health and safety, or to any individuals working at the facility.
.
The above cbservations were brought to the licensee's attention at the exit interview._ The licensee was informed that failure to implement procedure'AP-305-28 and the annunciator response procedure H2PSA-7 is sufficiently important to be considered an apparent
violation of TS, Section 6.8., " Procedures," which states " Written procedures shall,b'e~ established, implemented and maintained covering activities of applicable procedures, recommended in Appendix A of Regulatory Guide 1.33,' November 1972."
(50-312/86-06-05)
c.
Personnel Contaminations
'
During the course of the transient, three individuals became contaminated.
The three individuals were:
,
Auxiliary Operator (AO)
..
l
.
~
.l Equipment Attendant (EA)
Security Guard
i The A0 and EA were involved in isolating the makeup pump. Entries were made into the makeup pump room that is located on the -20 foot level of the auxiliary building. The Security Guard was in the process of making his rounds at the time of the event.
Respirators were not worn by the A0 and EA during their involvement
'
in the event. Both individuals stated that their efforts were l
focused on isolating what they believed to be a potential loss of coolant accident.
They wore the protective clothing which was readily available and performed a survey using a portable dose rate instrument. Their precautions, although not optimum were adequate since naither individual received a significant occupational
,
l exposure'. The licensee is considering placement of additional
peotective clothing and equipment at multiple locations in the l
facility to make it more available during circumstances such as this.
The AO, EA and Security Guard were found to have contamination on their personal clothing with the exception of the EA who also was found to have contamination on the skin of his hands. Clothing i
cortamination levels on the A0 and EA did not exceed 10,000 counts per minute (cpm). The EA's hands were contaminated to levels of approximately 400 cpm, which was removed by normal washing techniques. The extremity dose resulting from this contamination was minimal. Contamination was found on the guard's trousers. The i
levels found on his trousers were not documented as required by l
station procedures. The guard informed the CRA that the RM-14
personnel noq.itoring instruments located on the grade level were
!
. alarming piiur to exiting the area.
The CRA obtained a grab air sample on the grade level in an attempt to determine the source of contamination associated with the guard's l
clothing contamination; however, no contamination surveys (swipes)
,
!
were taken.on the grade level and no grab air samples or contamination levels were taken on the -20 foot level or in the makeup pump: room,by the onshift CRAs. The grade level grab air samples indicated the.following:
Kr 85m
'
1.57 E-7 uCi/cc 0.03 MPC
-
1.32 E-5 uCi/cc 1.32 MPC Xe 133
-
8.92 E-7 uCi/cc 0.22 MPC Xe 135
-
Several additional grab samples were obtained on the grade level between 5:30 a.m., and approximately 6:50 a.m.
Surveys of the-20 foot level were not performed until after 8:41 a.m.
The-CRAs informed the inspector that no surveys were performed on the l-20 foot level or in the makeup pump room because it was never l
requested by the EC.
Both the A0 and EA were whole body counted. The results of whole body counting indicated the A0 had one percent of Maximum
-
-
-
-
--
.
~
Permissible Body Durden (MPDD) of Silver-110M and the EA had 0.3 percent MPBB of Silver-110M. The Security Guard and other-members of the licensee's staff who were on shift at the time of the event were not.whole body counted.
l The inspection disclosed that no MPC hourly determinations for the A0 and-EA had been performed. This was discussed with the Radiation Protection Manager who indicated that station procedures do not currently provide instructions for performing hourly MPC determinations.
l The above observations were brought to the licensee's attention at l
the exit interview.
'
No violations or deviations were identified.
d.
Other Observations 1)
Isolation of Radiation Monitor R15001/ Fire Alarm At approximately 4:17 a.m.,
the safety features actuation system (SFAS) actuated containment building isolation. This signal also isolated suction to radiation monitor R15001 A&B and started both trains of CR/TSC essential Heating, Ventilation.and Air Conditioning (HVAC) system. The containment isolation caused the R15001 A&B radiation monitor motor and pump to overheat and damage its seals. The smoldering pump actuated the fire alarm. This caused the building ventilation. system to stop as designed. The licensee had not designed the.R15001 monitor pump to stop on an SFAS actuation. The licensee has repaired the pump and is evaluating a design change.
The inspection disclosed that no releases of radioactivity from l
the containment building were'in progress during the time of i
this event.
'No violations or deviations were identified.
2)
Securing CR/TSC HVAC System--
-
The EC 'st:Sted that the-actuation of the CR/TSC HVAC system l
significantly3 increased the noise icvel in CR.
Both A&B trains l
were secured during the event because of the high noise l
interference.
The inspection disclosed the following:
l The licensee's evaluation of the Control Room noise levels
'
l were last performed in November 1985. Noise levels for a single train running (e.g., A or B) were determined to be'
at 63 decibels (DB). This level is below the 65 DB level recommended by NUREG-0700. With both trains running the noise. level was determined to exceed NUREG-0700
.
-
- -
-
-
- - - - -
-
- -
. -
- -.
.
- -
-
"%.E ;s
~
i ; * 1.
-
s
!
,
<,a
>
- [3 ;
./s
-
.
.
-
.
-
4, ',
.
4-
-s 17.
.
tecommendations. The noise level with both Ltalus tunning was reported as 69 DB.
The Emergency Coordinator informed the inspectors that he considered the noise level with one train runn'ing unbearable.
- Based on interviews with representatives of the control room staff, the inspector found that no one clearly understood what actions would be required to initiate the ventilation system if it were necessary due to a change in plant conditions'such as high radiation.
- The Assistant Nuclear Operations Manager confirmed that the CR/TSC HVAC system is designed such that the "A" train would have automatically actuated upon receiving a high temperature signal.
The observations with respect to the noise problem and the licensee's staff unawareness of the system's operating characteristics were brought to the licensee's attention during the exit interview. This item will be examined during a subsequent inspection.
(50-312/86-06-06)
3)
The licensee's assessment of the radiological releases and conditions were complicated due to the inability to differentiate the various effluent radiation monitor' readings on multipoint recorder RJR-13.
In addition, another radiation monitor multipoint recorder (RJR-11) had run out of ink.
4)
The inspector observed that the licensee does not employ the use of portable continuous air monitors (PCAM) as a means of detecting airborne radioactivity levels in various areas throughout the plant. The licensee has approximately six General Atomics PCAM's that have'not been put into use even though they were purchased at least three years ago. A procedure (AP 305-27) has been developed for the use of PCAM's.
PCAM's are typically used to warn personnel of' abnormal airborne radioactivity levels.
The_-above observations were brought to the licensee's attention at the exit interview.
'
No violations or deviations were identified.
e)
Operations / Radiation' Protection Interface The-licensee's review of the event was documented on an Action Item Closure Report dated January 20, 1986. One item of the Action Item
-
Closure Report identified'the following programmatic weaknesses associated with the December 26,,1986 event.
,
.
.
f,.
The weaknesses identified included:
'
<,,
_
h f
-
'
,,
,,,,
~
sa 9,:
,
l#
' +
'
n;
,
,
_
,
p, y
~
,
jd (
.
,
..
.:
,
'
'
"Present procedures are inadequate to timely assess radiological releases and to determine 10 CFR 50.72.and Technical Specifications compliance especially if. radioactivity is present-iu.the secondary
'
system.
+,
.
,
Lack of communication between' operations and Health Physics, t
.
Lack of clearly defined separation of responsibilities for radiation protection between Operations'and-Health Physics.- Eg. is the Emergency Team capable of performing an assessment (gas, particulate, and iodine) in an area of unknown radiological conditions? There are presently no Health ^ Physics people on the Emergency Team.
Health Physics procedures to. respond.to. radiological events which
.are greater than routine but minor enough not to require implementation of the Emergency Plan."
It should be noted that historically. the licensee has considered operators, A0s and EAs to be qualified in radiation protection and has permitted them to take action independent of the radiation protection organization.. An evaluation of the communications implemented during the December 26, 1985 event' disclosed that this philosophy prevailed during the transient. As an example, the' health physics staff was not informed that the A0 and EA had been requested to enter the makeup pump room to isolate the pump. -If requested, the CRA's could have provided health
~
physics surveillance and all appropriate protective clothing and respiratory protective devices'for the entry.
The inspector noted that a similar problem with communications between operations and health physics has been previously identified. A licensee memorandum, dated June 13, 1985,. identified that improvemente in communications and a cooperative effort between operations.and health physics was needed to maintain a good radiation protection program.
- The above observations were brought to the licensee's attention at the w
exit interview. The licensees. actions in response to this issue will be
,
examined during a subsequent inspection.
(50-312/86-06-07)
6.
Exit Interview The inspectors met with the 11cen ee representatives.' denoted'in.
paragraph 1'at the conclusion of the inspection _~on January 24, 1986 and-February 6,,1986.
The scope'and findings of the inspection were summarized. The vio_lations' discussed in paragraphs 4.and * were brought
_
to the licensee's atte'ntion.' The NRC's Region _ V, Chief, Facilities Radiological Protection s'ated;that he falt the operating' staff on shift t
at the time of the event " focused their energies on mitigating the plant
'
transient,'as a result'seveial' elements..of the EPIPs and the licensee's radiation protection program were'.notLfully implemented. He stated that while the violations ;and deficienciesf observed with the implementation' of 1
.
their Emergency ~ Plan and Radiation Control Manual procedures did not jeopardizejthe.public health *and sa'fety/due to the minor radiological i
- l
' ! l, "
,
$ !
,_
'j;j
'
' '
,.
- p s i;
'
}
.
3,
.
'
consequences of this event, they do indicate a need for the licensee to improve their program, procedures, and training of the facility staff.
The inspectors also informed the licensee that it appears they have not been effective in correcting the communication problem existing between the site operation and radiation protection organizations.
The Chief, Facilities Radiological Protection complimented the licensee on their January 20, 1986 report, which described the results of their radiological investigation of the December 26, 1985 transient.
The licensee responded by stating that a similar investigation of the Emergency Plan implementation was nearing completion and that corrective measures will be taken.
l