IR 05000320/1986011

Safety Insp Rept 50-320/86-11 on 860903-18.No Violation Noted.Inadequacies in Licensee Program for Handling Sealed Sources Noted

ML20215E603
Person / Time
Site:	Three Mile Island
Issue date:	10/02/1986
From:	Bell J, Dan Collins, Cowgill C, Moslak T, Sherbini S NRC, Office of Nuclear Reactor Regulation
To:
Shared Package
ML20215E591	List: IR 05000320/1986011 ML20215E588
References
50-320-86-11, NUDOCS 8610150396
Download: ML20215E603 (5)

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U. S. NUCLEAR REGULATORY COMMISSION Report No. 50-320/86-11 Docket No. 50-320 License No. DPR-73 Priority --

Category C Licensee: GPU Nuclear Corporation P.O. Box 480 Middletown, Pennsylvania 17057 Facility Name: Three Mile Island Nuclear Station, Unit 2

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Inspection At: Middletown, Pennsylvania

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Inspecti Conducte : eSeptember h (1b, 1986 Inspectors:

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< W llins, Radiation Specialist d % Dido'

M.Moslak,ResidentInspector(TMI-2) io 2/es datei sfgned-er N ' l% $(o rx J . 1 S. ior Radi tfqn Specialist date signed a h \b/O Nb S.~She 'n Ra i 'o% Spec' litt cath signed Approved By: L R \b/A M4 C.'CowgTil, ' Chief, TMI-2 Project Section da~td sfg~ned Inspection Summary: Inspection conducted on September 3 - 18, 1986 (Report No. 50-320/86-11)

Areas InsSected: Special safety inspection conducted to evaluate the improper landling of a sealed calibration source by an individua Results: No violations were identified. However, significant inadequacies in the licensee's program for handling sealed sources were identifie PDR ADOCK 05000320 G PDR

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1.0 Overview This special inspection was conducted to determine the causes of an unplanned radiation exposure to the hand of a worker on Augu:t 27, 198 The worker inadvertently handled a sealed radioactive source containing 32 millicuries of cerium (Ce-144) for about 20-seconds. The worker sustained an estimated exposure of approximately 2.3 rem to the palm of his hand. The worker's whole body exposure was determined to be 108 mrem; however, this represents the exposure, based on an evaluation of the worker's personal dosimetry, for the period August 1 - 27, 198 Factors contributing to the incident were determined to be a failure to label tne source as radioactive material and a failure to adequately instruct the exposed individual on how to handle the sourc .0 Description of the Event On August 27, 1986, a sealed Ce-144 (~32 millicuries) source was to be taken into the reactor buildirg (RB) by the source custodian for the purpose of calibrating a portable gamma spectrometer. However, as the custodian was waiting in the contamination control cubicle (C-cube) of the' anteroom to the RB, for permission to enter the RB, he was notified that his task had been cancelled. The custodian then prepared to remove his protective clothing and respirator.

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Two workers were assigned to be in the anteroom full time to assist personnel when exiting the RB. One worker located in the C-cube (a plexiglas enclosure) helps workers doff protective clothing and places

, equipment in a transfer bin. The second worker, stationed outside the C-cube by the transfer bin, takes material from the bin to other plant area .

As the custodian was preparing to remove his protective equipment, he gave the source, contained in a plastic bag, to the worker in the C-cube and told him that the material was radioactive, and was to be given to Radiological Control personnel. Because the custodian was wearing a respirator while he was talking, what the custodian actually said was garbled and not clearly understood by the workers. The first worker picked up the source in the correct manner (by grasping the plastic bag at the top) and placed it in the transfer bin without telling the second worker what the material was. The second worker quickly picked up the source in the wrong manner (by holding the bottom of the bag in his hand)

and carried the source to the Radiological Control support area. At this time, the custodian noticed that the worker was carrying the source improperly and immediately took off his respirator and shouted for the worker to come back with the source; however, the worker was out of hearing range of the custodian's voice. Within 20 seconds of picking up the source, the worker entered the support area and placed the bagged source on a counter top. Several low level contamination monitors, located approximately eight and fourteen feet away from the source, alarmed. Radiological Controls technicians responded to the alarms. The technicians directed personnel to leave the room and surveyed the sourc The source was then returned to its storage container. Subsequently, the licensee initiated actions to determine the cause of the incident and to assess the dose to the worke ,

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3.0 Radioactive Source Characterization The source is cerium (Ce-144) in equilibrium with its daughter praseodymium (Pr-144). The activity was initially certified by the supplier on March 21, 1986, to contain 47.5 millicuries (mci), which had decayed to 32.1 mci on August 27, 198 As a result of evaluations, the licensee determined that during the incident: no beta radiation from Ce-144 or its daughter products contributed to the dose to the worker the effective energy of the photon field appeared to be about 20 kev the source could not be characterized as a point source when the source was improperly handled the source dose rate estimated under conditions that simulated the incident ranged from 1.627 rem to 2.322 rem for a 20 second perio .0 Licensee's Investigations and Corrective Actions The licensee held a critique of the incident on August 28, 1986 to

' identify the causes and initiate measures to preclude a recurrenc Corrective actions included assuring that source containers are labeled to indicate dose rates, quantity, and type of radioactive material; and restricting custody of sources to those personnel that had received specific instructions on handling them. Other sources that provide a similar hazard were identified and measures to reduce the radiation dose rates during transit were being evaluate The licensee performed various tests to evaluate the dose to the worker who improperly handled the source. Separate evaluations were made using survey meters, ionization chambers, and thermoluminescent dosimeters (TLDs) under conditions that simulated those during the inciden Dosimetry Investigation P.eport No. 2-86-374 addresses those actions taken to assess the exposure to the individual. Through these evaluations, the licensee estimated the dose to the hand was 2.322 rem for the twenty second ex This value was based on irradiating TLDs at a distance of Sm (posure. simulating the distance between the palm and the source) using the Ce-144 source. These irradiations yielded exposures ranging from 1.627 rem to 2.322 rem for a 20 second period. To be conservative, the licensee chose the highest dose value to assign to the worke .0 Inspection Findings The inspector reviewed the appropriate procedures, attended the licensee's critique of the incident, interviewed licensee representatives, and witnessed various evaluations performed to assess the dose to the individual. The inspector met with licensee representatives on September 17, 1986 to determine the progress in implementing the corrective actions and assessing dos , _ _ _ _ *

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During the course of this review, the inspector found that the licensee did not label the bag containing the Ce-144 to identify the hazardous condition and that the source was transferred to a worker who was not instructed on the precautions that should be taken when handling such a source. Through an examination of the ALARA Review, that was developed to identify the radiological controls to be implemented when using this source, the inspector determined that it did not address controls to be used when transferring the source to/from the job site. The inspector also concluded that the source could have been encased with appropriate materials to reduce the radiation field thereby reducing the personnel hazard when handling the sourc The inspector discussed these items with the licensee who stated that response will be sent to the NRC documenting the actions taken to improve the handling of sealed sources. (320/86-11-01)

The inspector concluded that the licensee's investigation was thorough and that the dose assessment was reasonabl The inspector determined that the licensee actions surrounding the incident met the criteria of Appendix C of 10 CFR 2, for self-identified items, and as such a Notice of Violation will not be issue .0 Persons Contacted 6.1 During the inspection the inspector contacted the below listed individuals. Other persons were also contacte *** U. H. Behling, Manager, Radiological Health B. Brosey, Data Management and Acquisition

• • J. J. Byrne, Manager, THI-2 Licensing

• • W. C. Craft, III, Manager, Rad Con Field Operations

• R. Croll, Radiological Engineer

• • • C. Dell, TMI-2 Licensing, Technical Analyst

• • T. F. Demitt, Deputy Director, TMI-2 C. Distenfeld, Data Management and Acquisition

• • S. Levin, Site Operations Director

• G. M. Lodde, Consulting Radiological Engineer A. Paynter, Group Radiological Controls Supervisor 0. R. Perry, Dosimetry Manager, Radiological Controls

• • • M. J. Slobodien, Manager, Radiological Controls J. Sprucinski, Group Radiological Controls Supervisor

• J. E. Tarpinian, Deputy Manager, Radiological Engineering

• Atter.ded meeting, September 17, 1986

• • Attended exit interview, September 18, 1986

• • • Attended meeting of September 17, 1986 and exit meeting of September 18, 1986 6.2 Additional NRC Persons:

J. M. Bell, Senior Radiation Specialist, TMI-2 T. A. Moslak, Resident Inspector, THI-2 L. E. Myers, Radiation Specialist, TMI-2

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M.-M. Shanbaky, Chief, Facilities Radiation Protection Section (FRPS),RegionI S. Sherbini, Radiation Specialist, FRPS

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7.0 -Open Item Matters that require further review and evaluation by the inspector Open items are used to document, track, and ensure adequate followup on matters of concern to the inspecto Open items are addressed in paragraph .0 Exit Interview The inspector conducted an exit interview on September 18, 1986 to discuss the scope of the inspection and present the findings to the licensee. The licensee's attendance at the exit interview is indicated in paragraph At no time during this inspection did the inspector provide written material to the license .

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