IR 05000320/1989013
| ML20005F031 | |
| Person / Time | |
|---|---|
| Site: | Crane  |
| Issue date: | 12/29/1989 |
| From: | Ronald Bellamy, Pasciak W, Sherbini S NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML20005F029 | List: |
| References | |
| 50-320-89-13, NUDOCS 9001120201 | |
| Download: ML20005F031 (8) | |
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U. S. NUCLEAR REGULATORY COW 41SSION
REGION I
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3-Report No.
50-320/89-13 l
Docket No.
50-320 License No.
DPR-73-j
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Licensee:
GPU Nuclear Corporation P. O. Box 480 Middletown, PA 17057 Facility Name:
Three Mile Island Unit 2-Inspection At:
Middletown,-Pennsylvania Inspection Conducted: November 30, 1989 and December 15, 1989
a/v//E7 Inspectors:
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5. Sherbini Senior Radiation Specialist date Facj;11tierhd ation Protection Section l
Mae
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/W. Pasciak,Section Chief, facilities Radiation
/daKe '
Protection
., Facilities Radiological
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Safety and Safeguards Branch
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Approved by: bd k.
T M A t9/ 9 P 'l
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Factlgles Radiological date R. Bellamy, Chief, ds Branch, Divisior, of
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Safety & Safeguar Radiation Safety and safeguards Inspection Summary: Inspection on November 30, 1989 and December 15, 1989
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(Report No. 50-320/89-13)
l Areas-Inspected: A reactive inspection to review the circumstances connected l
with an unplanned exposure of a Radiological Controls Technician associated with the removal of fuel fines from the reactor vessel.
L was a failure to adequately survey an end-plug be(Section 5.0)from the reactor Results: One apparent violation was identified The violation
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ing removed L
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vessel which resulted in improper removal of material from the vessel and in
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an unplanned exposure of an individual to radiation.
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900112O201 891229 -
-PDR-ADOCK 05000320.
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DETAILS 1.0 Personnel Contacted
- M. Roche, Director, Unit-2-
- J. Kuehn, Site Operations Director
- T. Murphy,Defueling DirectorRadiological Controls Director, TMI-2 i
Unit-2
- S. Levin
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C.Whitaker,DefuelingSeniorO Group Radiological Controls Supervisor D. Hollman, M. Kovach, Utility Worker "A" perator B. Novac, Auxiliary perator "A"
-J.
Barry, Auxiliary perator "A" K. Barth, Radiolo ic 1 Controls Technician
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T. Dupes, Radiolo ical Controls Technician E. Smith Radiolo ical Controls Technician S. Laskoski, Boilermaker G. Strachan, Boilermaker 1.1 NRC Personnel
- M. Knapp, Director, Division of Radiation Safety and Safeguards Senior Resident Inspector
- F. Younbl, Project Manager
- C. Cowg Chief, Reactor Projects Section - 4B L. Thonus,.
,.NRR l'.2 Pennsylvania Department of Environmental Resources (PDER)
- R. Cook, PDER Inspector
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Denotes attendance at the exit meeting
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2.0'Backgroug.1 On Nov(rnber 28, 1989 two auxiliary operators were removing an end-plug device from the reactor vessel by means of a long tool Peters tool).
The Peters tool that was used was a long aluminum rod ab(out three-quarters of an inch in diameter with a vise-grip type device on one
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. end that could be controlled from the other end. The end-) lug was about I
two and one-half inches in diameter and two inches in heig1t and was of a cup like configuration open on one end. The plug was removed from the vessel apparently full of fuel fines. The presence of these fuel fines l
led to an unplanned exposure of a Radiation Controls Technician (RCT).
3.0 Description of the Facility l
The work area in which the incident occurred was the Reactor Defueling Platform located about seven feet above the water surface in the reactor vessel. The platform is shielded and covers the entire reactor vessel.
In its center is an arrangement oi' slots in the shape of a "T" that
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allows -operators standing on the platform access to the reactor vessel.
positions of the individuals involved during the incident. proximate-Figure 1 depicts the arrangement of the "T" slot and the ap There is a rail that boarders the "T" slot of ap)roximately three feet in height.
The rail's sides are covered with a s tield for radiation protection pur-goses. Off te one side of the "T" slot is an area designated as the
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local service panel" essentially a table, which is used by the radia-o tion controls technicians in handling materials removed from the vessel.
4.0. Description of the Incident
The sequence of events described here was determined through discussions with the individuals involved-in the incident. There are some discrepancias in the accounts of the events as related to the inspectors.
In Section 4.1 below the discrepancies are presented in further detail.
The incident occurred early during the third shift (2:15 a.m. on November l
28,1989. During the end of the second shift the end-plug was removed i-from the) hose it was in by means of the Peters tool described in Section 2.0 and the plug-was left in the tool at the bottom of the vessel by the L
boilermakersonsecondshift. According to the second shift boilermaker
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who removed the end-plug,f the plug was oriented upward.the position of the p
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such that the open bowl o This
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orientation supports the statement by the RCT that the arount of fuel i
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fines that were removed was about that of a full cup. The second shift boilermakers exited the containment building at about-1:50 a.m, Figure 1 depicts the approximate location of the two auxiliary operators, the crane operator and the radiological controls technician wten the incident occurred. The auxiliary operators' job was to pull up the l
Peters tool from the vessel in order to retrieve the reusable end-plug.
As they pulled it up out of the water in the "T" slot through the area of whiie at the same time-the rails-they wiped it down with a clean cloth,he end of the tool got to the RCT surveyed the pole. When the object at t the height of the rails where it could be grabbed, the RCT surveyed it to determine if the dose rates on it were low enough to remove it from the
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vessel.
The RCT did not give the auxiliary operators an indication that i
there were any unusual dose rates associated with the end-plug.
The RCT stated that there was no change in the meter reading when the object initially broke water'nor was there any marked increase in the me-
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ter reading when the object was up to the point where it was removed from j
the end of the Peters tool. When it was removed from the tool it was dropped into a semitransparent plastic bag along with the wiping cloth.
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The auxiliary operator who performed the actual bagging stated that because he did not want to drop the plug back into the vessel he was
leaning way over the rail and down between the rails, and bagged the end-plug more quickly than usual. The RCT also stated that the end-plug was bagged much more quickly than normal. The auxiliary operator stated that the RCT seemed surprised that the operation went so quickly and l
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hastily snatched the bag out of the his hand. The auxiliary operator said that while he was working the Peters tool and bagging the end-plug he thought that the RCT's survey meter was somewhere up over or'near his head. The RCT stated.that his survey meter was below the operator's
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hands during the entire operation.
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Once the RCT had the bag with the end-plug in '.t in his hands' he took it over to the local service panel and put it down. Hethennoticedsome water in the beg. He put his hand in the bag and grabbed the towel that was already.in there and used it to wipe up the water.
He did not perform a survey before putting his hand in the bag.
He then took the towel out and did a contact surve He measured 35 R/hr closed
.windowandoffscaleopenwindow(yofit.
>50 R/hr. - He then put the towel in a He also not9ced that)some fuel-fines were in the bag second plastic bag.
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with the end-plu. He put a beta glove on, put his hhnd in the bag, grabbed the end-lug, knocked it on the table inside the bg to shake Nt any fuel fines i it, removed it from the bag and placed it on the end cf the table. He said that there was about a full cup of fuel fines in the bag. During this time the RCT was in communication with the Command Center. The Command Center's direction was that he shake the bag over the slot to return the fuel fines to the vessel, which he did. He was also ditated to have the auxiliary operators put the end-plug in a submerged fuel canister located in the vessel. He held the end-plug over the slot fer the operator to clamp it with the Peters tool and then it was placed in the fuel canister. The RCT then took the second plastic bag which contained the wipe cloth and placed it-at the North end of the defueling platform.. During-this time the RCT made several surveys of the end-plug and the fuel fines in the bag. The end-plug on contact with its open side measured 5 R/hr gamma and 80 R/hr beta. The fuel fines in the bag exhibited dose rates that were offscale open and closed window at contact, and at fourteen inches were 15 R/hr gamma and 80 R/hr beta. The
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survey results along with the RCT's comments appear in the attached i
L survey sheet (Enclosure 1).
b 4.1 Discrepancies L
There were several discrepancies in the accounts of the various l
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individuals that were interviewed by the inspectors.
They are as follows:
The auxiliary operator who bagged-the end-31ug stated that he
thought the RCT s meter was up around his lead.
The RCT stated that his meter was below the operator's hands.
No one else on the platform could comment on this aspect of the operation.
The RCT stated that the Peters tool and end-plug were flushed on the
second shift and put back in the vessel, and that it was not flushed a second time by the operators when they removed it on third shift.
One o)erator said that it was flushed during re:noval on third shift and tie other said he thr,ught it was but could not remember who did it.
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The RCT stated that the beta dose rates deep into the slot were 5-8-
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R/hr when the operation was going on. Measurements made by another RCT afterward did not support the 5-8 R/hr measurement - but were in the area of a few hundred mR/hr.
Itisnotknownwhetberthesecond survey covered the exact areas as the initial survey.
5.0 Apparent Violation cause to be ma(de) requires, in part, that each licensee shall make or 10 CFR 20.201 b such surveys as may be necessary and renconable to ensure compliance with the requirements of 10 CFR Part 20.
10 CFR
- 20.201(a) defines a survey, in part, as an evaluation of the radiation hazards-incident to the presence of radioactive materials under a specific set of conditions. When appropriate, such an evaluation..
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includes a physical survey of material and equi > ment and measurements of levels.of radiation present. Contrary to the a)ove, at aporoximately-2:15 a.m. on November 28, 1989, inadequate surveys were made to assure o
compliance with that part of 20.101 which limits radiation dose to individuals in restricted areas. Specifically, a hose end-plug fitting was removed from the reactor vessel and handled by two technicians
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o without properly measuring the radiation dose from the end-plug. This resulted in an unplanned radiation exposure to one of the technicians and in the inappropriate removal of contaminated material from the reactor vessel Corrective actions for this apparent violation will be reviewed during a future inspection.
(50-320/89-13-01)
5.1 Program Weaknesses The following program weaknesses were identified as part of the inspection and discussed during the Enforcement Conference on December 4, 1989,
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The RCT stated that the background dose rate in the vicinity of v
where surveys were being made of the Peters tool and the end-plug were 5 to 8 R/hr beta.
It was not clear to the technician what an acceptable background dose rate is for making such surveys.
In
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discussions the inspectors had regarding this with other RCTs, it
appeared that.there was a confusion among the RCTs what acceptable
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backcround levels are. One RCT said that an acceptable background l'
woulc be about 2-3 R/hr,le.open window, and another said 1 R/hr open window would be acceptab The licensee should modify procedures to provide clear directions to RCTs as to what background levels are acceptable for survey work and what should be done when the
specified levels are exceeded. Direction. should be clarified for lL all types of future work where there is a potential for high l
background dose rates.
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The end-plug was removed from the vessel without having received an adequate survey. Survey procedures for all types of future work
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I should be upgraded to ensure that adequate surveys are performed.
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'The procedures need to take into consideration the possibility'of
' objects with very high beta to gamma ratios and the particular problems of surveying ob ects with this type of contamination.
.rf Procedures should clarif how surveys are to' be made, for example open or closed window an survey distance. Where appropriate, special equipment should be specified.
The end-plug was bagged for removal from the work slot much more
quickly than usual without receiving oral approval from the RCT.
The rapidity in which the end-plug was bagged may have contributed to the inadequacy of the survey.
The practice has been that the
.o>erators may remove objects from the vessel unless the RCT tells ties not to.
Licensee procedures should be revised to require l
a) proval-by-the RCT at critical points in the progress of each job.
Tiese critical points-should be designated for each type of future
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job and clearly communicated to workers and to the RCTs.
The RCT handled the end-plug prior to performing an adequate survey
- on it. While in this case the RCT may have thought he performed an adequate survey, in actuality he did not. The licensee should
empha:ize to the RCTs the importance of performing radiclogical surveys on objects before handling them.
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These weaknesses will be reviewed during a future inspection.
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(50-320/89-13-02)
6.0- Follow-up Inspection on December 15, 1989 On December 15, diatio.a follow-up inspection to review the licensee's 1989 retraining of ra n control technicians and workers was conducted.
L Several RCTs and workers were interviewed by the inspector.
Both workers and RCTs had received additional training since the November 28,
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1989. incident. The-training focused on the importance of-following
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licensee procedures when removing objects from the vessel. A new form
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was developed to ensure more thorough surveying of objects. Also hold points have been established for critical stages of job evolutions to provide for RCT approval.
The licensee was briefed on the results of this follow-up inspection on December 15, 1989. Mr. Thomas Murphy attended the briefing.
7.0 Exit Interview The inspector met with the licensee personnel denoted in Section 1.0 at l-the conclusion of this inspection on November 30, 1989. The scope and I
findings were presented at that time.
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Radiation Controls Technician Local Service Panel
"T" Slot Plan View Figure 1
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