IR 05000324/1992032
| ML20128C072 | |
| Person / Time | |
|---|---|
| Site: | Brunswick  |
| Issue date: | 11/24/1992 |
| From: | Rankin W, Testa E NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| To: | |
| Shared Package | |
| ML20128C045 | List: |
| References | |
| 50-324-92-32, 50-325-92-32, NUDOCS 9212040217 | |
| Download: ML20128C072 (19) | |
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A Q "{o NUCLEARR T RY COMMISSION
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j 101 MARIETTA GTREET, e ATt.ANTA, oEoRGI A 30323
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NOV 2 4 B9 Report Nos.: 50-325/92-32 and 50-324/92-32 Licensee: Carolina Power and Light Company :
P. O. Box 1551 Raleigh, NC 27602 .
Docket Nos.: 50-325 and 50-324 License Nos.. OPR-71 and DPR-62
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Facility Name: Brunswick 1 and 2 Inspection Conducted: Septemb.er 24-28, 1992, and October 26 '^, 1992 Inspector: bu b ////kf1 Dhte Signed
E. D. Testa Accompanying Personnel: D. B. Forbe Approved by A Nnd[
' W. H. Rankin, Chief'
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Facilities Radiation Protection Section Radiological Protection and Emergency Preparedness Branch Division of Radiation Safety and Safeguards
! SUMMARY Scope: ,
o A reactive inspection related to the unplanned cutting of an Americium / Beryllium source which resulted in an inadvertent spread of-Americium-241 (Am-241) was conducte In addition, a routine and a followup' announced inspection of the licensee's Radiation Control (RC) program was conducted involving a review of Health Physics (HP) activities including organization and staffing; training and qualifications; internal and external exposure controls.; control-of radioactive material; and ALARA program implementation primarily associated with maintenance Outages B1-08-F9 and 82-10-F6 activitie .
Results:
In the areas inspected, three apparent. violations were identified, i
The first apparent violation was observed for workers 'in Radiological, Control Areas'(RCAs) who were not signed in on.any Radiation Work Permit (RWP).and/or were' signed in on an incorrect RWP.(Paragraph 5.'a). A second apparent violation of 10 CFR 20.203(f) for failure to provide a readily available written record of the Am-241. source was identified (Paragraph 8 c) . 'The third p$k20gock0$00 G
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REPORT DETAILS Persons Contacted Licensee Employees
+ Ahern, Manager, Unit 2 Operations
- Alford, Manager, Nuclear Engineering
+ Bean, Manager, Quality Control
+* Boone, Specialist, Regulatory Compliance
+#J. Brown, Plant Manager, Unit 2 (Acting)
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3. Brown, Corporate, Dosimetry
+*S. Floyd, Regulatory Compliance
- S. Gallis, Licensing
- R. Godley, Manager, NRC Compliance
+* Gurganious, Senior Specialist, Nuclear Assessment Division
+ Helme, Manager, Technical Support
+*J. Holder, Manager, Outage Management and Modifications
- T. Jones, Senior Specialist, Regulatory Compliance
- P. Leslie, Security Supervisor
- Miller, Nuclear Systems Engineering
+ Moore, Manager, Maintenance, Unit 1
- Neushaver, Corporate, Environr.: ental and Radiation Control
- Noland, Manager, Operations Staff
- T. Priest, Outage Management and Modifications Specialist
+#C. Robertson, Manager, Environmental and Radiation Controls
+*R. Smith, Supervisor, Radiation Controls
+*P. Snead, Supervisor, Radiation Controls
- J. Spencer, General Manager
- J. Terry, Radiation Control Special Projects
+J. Titrington, Manager, Unit 1 Operations
- L. Tripp, Outage Management and Modifications Specialist
- G. Warner, Manager, Control and Administration -
Other licensee employees contacted included engineers, technicians, and-
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office personne Nuclear-Regulatory Commission ,
P. Byron, Resident inspector
- H. Christensen, Branch Chief, Reactor Projects
- #W. Cline, Branch Chief, Radiological Protection and Emergency Protection Branch
+0. Nelson, Resident inspector
+*D. Prevatte, Senior Resident Inspector
- W. Rankin, Chief, Facilities Radiation Protection
- Attended September 28, 1992, Exit Meeting
, + Attended October 30, 1992, Exit Meeting ll # Attended November 12,1992, -Telephone Conference Call- Exit _ Meeting L
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2 Organization and Staffing (83729)
The inspector reviewed and discussed with-licensee representatives changes made to the Radiation Control (RC) organization since the last inspection in this area conducted March 9-13, 1992,-_and documented in Inspection Report (IR) 50-325,324/92-06. Cognizant licensee representatives stated that some changes had been made to the organizational structure and lines of authority as they related to the-RC function. The inspector noted that changes-involved the reassignment of an ALARA Manager and an RC operations supervisor. The manager of-E&RC now reports to a new position. This new position is the Manager of Control and Administration. The vacated positions were filled from within the RC group with no loss in program continuity. The~recent organization reporting change for the E&RC manager will be evaluated during future inspection The licensee continued to maintain a core technician staffing of approximately 45 RC technicians. For Outages B1-08-F9 and 82-10-F6, the inspector noted that approximately 94 contractor health physics (HP)
technicians were employed to supplement the routine staff. This number included senior technicians, junior technicians, and HP clerk Based on discussions with licensee representatives and observations of activities in progress, no concerns were identified regarding the licensee's organization and staffing._ The staffing levels. appeared adequate to support ongoing and planned outage activities.
l No violations or deviations were identified in this are . Radiation Protection Training (83729)
10 CFR 19.12! requires, in-part, that the licensee instruct all individuals working in or frequenting any portion of- a restricted area in the health protection aspects associated lwith exposure to radioactive-material or radiation; in precautions or procedures to minimize exposure; in the purpose and function of protection dev_ ices employed; in the applicable provisions of the Commission regulations; in the individual's responsibilities; and in the availability of-radiation exposure data, General Employee Training (GET)
Licensee Administrative Instruction, AI-13, Revision (Rev.) 5, described the training program for employees granted unescorted access to the Brunswick site. GET was di.vided into two levels, depending on.the degree-of access required. Level I training-was-provided to employees needing unescorted access to only the protected area. -For workers needing unescorted access to the radiologically controlled' area (RCA), Level 11 training-was L required, in addition to Level I. Both levels _of training required personnel t: pass an examination with a minimum passing score of 80' percent.
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.i The inspector-attended a GET Level II. course lecture,E and reviewed : 1 lesson plan GET Level II, Rev. 0,- dated November 27, 1991, and- j study guide _LPN-17, Rev._1, dated May 28, 1992, which was_provided to the attendees. The major focus of the lecture-included safety, '
fitness for duty, workers rignts. heht~ stress, chemical control, -
hazardous waste, and-emergency .:sponse . .The lecture and lesson plan provided acceptable training. <
Additional enhanced training.for RC included: Two RC managers completed a four month managers Advanced Systems Trainireg program-and 82 percent of RC Technicians completed a two day training course on the-new 10 CFR 20 regulation Based on the review of G6iected training proceJures, examinations, course outlines, and course lecture the inspector determined that the. licensee's GET program met the provisions of 10 CFR 19.1 No violations or deviations were. identified in this are . External Exposure Controls (83729) >
10 CFR 20.101 requires that no licensee possess, use, or_ transfer-licensed material in such a manner as to cause any-individual-in a restricted area to receive in any period of one calendar quarter a total occupational dose in excess of 1.25 rem to the whole body, head and -
truck, active blood forming organs, lens of _ the eyes, or gonads; 18.75 rem to the hands, forearms, feet and ankles; and 7.5 rem to th skin of the whole bod Personnel Dosimetry 10 CFR 20.202(a) requires each licensee to supply appropriate monitoring equipment to specific individuals and requires the use i- of such equipment.
i 10 CFR 20.202(c) requires that dosimeters used to_ comply with 10 CFR 20.202(a) 'shall be processed and evaluated by a processor L accredited by the National- Voluntary Laboratory Accreditation
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Program (NVLAP) for the types of radiation for which-the individual is monitored.
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The-inspector reviewed and discussed the licensee's dosimetry _
program with Corporate and site personnel. The licensee employed the Panasonic UD-802 thermoluminescent dosimetry (TLD) syste *
- The TLDs consisted of two lithium borate-elements with density
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thicknesses of 14 mg/cm2 and 350 mg/cm and two: calcium sulfat elements with density thicknesses of 350 mg/cm' and 1000.mg/cm2 ,
The . inspector was informed that a TLD analysis algorithm corrected:
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the measured values to report deep and shallow dose at 1000 mg/cm2 and 7 mg/cm', respectively. The TLDs were processed onsite-by the-dosimetry _ group, and the inspector noted-that the licensee was NVLAP accredited in all eight dosimetry categorie The inspector reviewed the-licensee's program for evaluating neutron dose to the whole body. The licensee stated that the computerized TLD algorithm used for high energy neutron exposure during operations is manually adjusted by the site on a case to case basis for lower energy neutron exposure evolutions which may =
be performed during outage period The inspector reviewed the 1991 Monthly Background TLD Data for Brunswick. These data are used to correct Personnel TLD result The background was measured at the Primary Access Point (PAP) and-at the Secondary Access Point (SAP) using the same TLD with four chips (E1...E4). -The data also includes the average Reactor Power .
for Unit 1 and Unit'2 for the month as well as Hydrogen Water Chemistry Injection Rates. The background control badge values a the PAP peaked-in March with 57.6 mrem and both units at 100 percent power and a Unit 2 hydrogen injection rate of 1 standard cubic feet per minute (SCFM). The 1991 control badge data are presented in Table 1 (Attachment A).
No violations or deviations were identified in this are Whole Body Exposure The inspector discussed the cumulative whole body exposures for plant and contractor employees. Licensee representatives state and the inspector confirmed that all whole body exposures assigned -
since the previous NRC inspection of this area were within 10 CFR-Part 20 limits. Review of pertinent records revealed that the whole body average exposure for an individual' for 1992, is currently 87 mrem based on approximately 4400 occupational radiation worker No violations or deviations were identified in this are . Operational and Administrative Controls (83750) Radiation Work Permits (RWPs)
The inspector reviewed selected routine and special RWPs associated with Outages B1-08-F9 and B2-10-F6 activities for adequacy of the radiation protection-requirements based on work scope, location, and conditions. For_the RWPs-reviewed,-.the inspector noted that appropriate protective clothing, respiratory protection, and dosimetry were require a-O
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The inspector observed L, .afings conducted for workers prior to -
entering the RCA. The briefings included reviews _of. current radiation surveys with emphasis on high dose areas and low dose waiting areas. The interaction b6 tween RC and the' workers entering the RCA, in this regard, was considered adequat During a tour of the site on October 28, 1992, the inspector - 'l; observed the movement of the F015A Disc and Valve Stem from the-North Breezeway to the Decontamination Trailer. The inspector ,
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noted that a forklift truck and physical assistance by_ several workers was necessary to remove' the' valve stem from the forklift
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truck and place the F015A Disc in the trailer for decontaminatio l The stem was placed on the ground until the disc was positioned _ l inside the trailer and the stem was again placeci on the forklift I for transport to the hot shop. At the conclusion of-the work,-the inspector reviewed pertinent RWPs and found that the forklift operator and three of the individuals providing handling assistance were not signed on RWP 0531, Rev. 01 or RWP 1908, Rev. 02 as required by Step 10.4 of Procedure 0-E&RC-0230, Rev. 25, dated September 24, 1992, titled " Issue and Use of Radiation Work Permit." Survey. 1024-50 of the disk and stem ,
indicated up to 450 mrem contact and 200 mrem at 18" on the disk and up to 150 mrem contact on the valve stem. This was identified ,
as an apparent violation of failure to follow procedure Violation (VIO) 50-325,324/92-32-01: Failure to follow E&RC Procedure 0230, Rev. 2 One violation and no deviations were identified in this area, b, Notices to Workers 10 CFR 19.ll(a) and (b) require, in part, that the licensee-post current copies of 10 CFR Part 19, Part 20, the license, license conditions, documents incorporated into the license, license amendments and operating procedures, or that a licensee post a-notice describing these documents and where they may be examine CFR 19.ll(d) requires that a licensee post Form NRC-3,_ Notice
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to Employee Sufficient copies of the required forms are to be posted to permit licensee workers to observe them on the way to or-from licensed activity locations, t
During the inspection, the inspector verified that current NRC-L form-3(s) were posted properly at various plant locations l permitting adequate worker access. In addition, notices were posted referencing the location where the license, procedures, and supporting documents could be reviewed.
l No violations or deviations were identified in this area.
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6 l 0 Control of Radioactive Material and Contamination, Surveys, and Monitoring (83729) i 10 CFR 20.201(b) requires each licensee to make or cause to be made such surveys as (1) may be necessary for the licensee to comply;with the _
regulations and (2). are reasonable under the circumstances to evaluate the extent of radiological hazards that may be presen Posting and Labelling ;
10 CFR 20.203(f) requires, in part, each container of licensed material containing greater than Appendix C quantities bear a durable, clearly visible label identifying the radioactive contents and providing sufficient information to permit individuals handling or using the containers, or working in the vicinity thereof, to take precautions to avoid or minimize exposure During tours of the Containment Building, Turbine Building, Waste
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Processing Building, and various radioactive material storage-locations including outside storage areas, the inspector noted that radioactive material areas were appropriately posted and containers were labelled consistent with regulatory requirements with one noted exception (Paragraph 8).
No violations or deviations were identified in this are Personnel and Area Contamination The licensee maintained approximately 35,907 square feet (ft2 ) of floor space as radiologically controlled. As of October 30, 1992, this represented approximately 6.0 percent of the RCA. The inspector noted that for the current stage of Outages B1-08-F9 and 82-10-F6 activities, the licensee efforts in this area were Judged-appropriat As of October 30, 1992, approximately 125 Personnel Contamination
- - Events (PCEs) had occurred in 1992 compared -to a 1992 c9al of 180.
i- During plant tours, the inspector generally observed-appropriate-L housekeeping and contamination control practices.
No violations or deviations were identified in this area, High Radiation Areas Technical- Specification (TS) 6.12.1 required, in part, tha_t- each
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L High Radiation Area-_(HRA) with radiation levels greater than or >
l- equal to 100 mrem /hr but less than or equal- to 1000; mrem /hr be i barricaded and conspicuously posted as a HRA. In addition, any individual or group of-individuals permitted to enter such areas are to be provided with or accompanied by a radiation monitoring-I i
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device which continuously indicates the radiation dose rate _in the area or a-radiation monitoring device which._ continuously integrates the-dose rate in the area, or an individual qualified-in radiation protection procedures with a radiation dose rate monitoring devic During tours of the Containment, Turbine, and Waste Processing Buildings,_ the inspector noted that all HRAs-and locked HRAs were observed to be locked and/or posted, as required. During the preplanned hydro-lasing evolution to remove hot spots in _ floor drains, the inspector observed licensee actions for surveying potential HRAs and adjusting postings as necessary as a result of 4 transient radiation levels. The hydro-lasing activities are part of a hot-spot reduction program as part of the licensee's as. low as reasona'ily achievable (ALARA) activities. The_ inspector obse- sed the use of portable HRA gates recently installed outside HRA's to heighten worker awareness of HRA rio violations or deviations were identified in this area; Radiation Detection and Survey Instrumentation ,
During-facility tours, the inspector noted that survey instrumentation and continuous air' monitors in use wi_ thin the-RCA were operable and displayed current calibration stickers. The-
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inspector further noted an adequate number of survey instruments were available for use, and background radiation levels- a personnel survey locations were observed to be within the f licensee's procedural limit of 300 counts per minute (cpm) with-
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tha exception of a frisking booth located outside the Radioactive M terial Storage Building. The> 1icensee had initiated procedural '
changes to move the frisking booth to a lower background location, which was accomplished during the course of the inspectio No violations or deviations were identified in this area, Independent Surveys During facility tours, the inspector selectively verified radiation and/or contamination levels in the Turbine Building, Waste' Processing-Building areas, the Containment Building, and-
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other radioactive material storage areas. The inspector also performed radiation surveys of selected HRA boundaries. .The L
radioactive and/or contamination levels checked by the inspector (
wt:re found to be as described on survey (s) and/or RWP(s).
i No violations-or_ deviations were identified in this are i
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7. Program for Maintaining Exposures As Low As Reasonable Achievable (ALARA) (83729)-
10 CFR 20,1(c) states that persons engaged in activities _under licenses ,
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issued by the NRC should make every reasonable effort to maintain radiation exposures ALAR Regulatory Guides 8.8 and 8.10 provide information relevant to attaining goals and objectives for planning and operating light water reactors and provide general philosophy acceptable to the NRC as a necessary basis for a program of maintaining occupational exposures ALAR '
The licensee collective dose continues to trend downward during outage The licensee has continued to reduce collective dose as shown below:
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1992 projected exposure goal = 672 Person-rem a
1992 Exposure through November 06, 1992 - 510 Person-rem i
1991 Exposure - 778 Person-rem ;
- 1990 Exposure - 1548 Person-rem The licensee estimated a savings of 555 Person-Rem during this outage due to the following: chemical decontamination of the Recirculation System piping, and increased use of temporary shielding and nozzle flushes. The addition of a surrogate tour system with seven computer stations, and increased use of remote video cameras aided in radiation work planning. The licensee has _ replaced 32 video cameras in the Turbine Building and has added an additional 16 cameras. The licensee has added six additional cameras to the Reactor Building. This is an ALARA dose reduction initiativ No violations or deviations were identified in this-are . Americium-241-Event Details of September 22, 1992 Initial Conditions -
Both Units 1 and 2 were in cold shutdown in a maintenance outage-
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that began April 1992. Unit 1 spent -fuel pool (SFP) had been cleaned up and material had-been removed for disposal. The final stage of the cleanup of the Unit 2 SFP was in progress. Old and discarded material' was being removed for disposa In early to mid;1970s, two huericium Beryl'lium sources were purchased by CP&L for use at the Brunswick plant. The first source was receivsd in 1974.' -In 1976, this. source was shipped to the Harris Energy and Environment Center:(HE&C)1where it remainst today. It is on the HE&C .llcensed matorial inventory. There is=
no evidence that this source was.ever placed on an inventoryLat the Brunswick plan . .
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In December of 1978, the second Americium-Beryllium source arrived '
at Brunswick. _ Records of the receipt inspection have been found but no inventory record for this source has been locate ,
The procedure used to govern inventory of-sources during this time-was RC&T 7005. Though records of the existence of this procedure- i have been located, no actual copy of the procedure could be found-at the time of the inspection, therefore what the procedure requires could not be determined. Evidence indicates that only -
calibration sources were actually inventoried under this procedure. No procedure was found describing-the responsibility-and the method for placing a newly acquired source on an inventory. This situation was found to exist at the time of this inspectio In 1978, the Unit 2 SFP was completely drained for inspection and cleanu This established a bench mark for material in that SF It is believed that the second source was obtained for use in ,
maintaining the Source Range Monitor-(SRM) minimum count rate at the beginning of the reload of Unit 2 in 1979. The source would have been removed once an adequate response on the SRMs was obtained and so it would not have been irradiated. When no longer needed, the source tube containing the source was placed in a holder located on the south wall of the pool near the east side of the fuel pool gates. Though only anecdotal evidence supports this supposition, this is in-the vicinity of this position that-the source tube was discovered in:199 In 1987, a clean up of the Unit 2 SFP occurre The source tube was not located during this clean up, In an attempt to gain control over items-placed.in the SFPs, a new procedure Al-ll2 was written in 1990. This procedure requires that items suspended from the SFP railings from 1990 on be labelled so as to provide identification of contents. The procedure Al-ll2 was written in response to Information Notice (IN) 90-33- dated May 9,-1990, titled L" Sources of Unexpected Occupational Radioactive Exposure at Spent Fuel -Storage' Pools."
This procedure did-not require that an inventory of. existing SFP-cur. tents nor does it require that an inventory -be maintaine In May of 1992, the clean up of-the Units 1 and 2 SFPs began. The-cleanup was performed by a contractor working under the direction of-Outage Management and Modification (OM&M). The' cleanup'was originaily planned to focus on removing the identified. radioactive waste in the fuel pools as specified by a list developed.by-Technical Support. Although this list was known to be incomplete, it was the best accounting available and was thought to contain--
the most imortant items. The contractor developed a handling
, procedure for each type of waste (i.e., shroud head bolt, LPRM, miscellaneous unirradiated waste).
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Subsequently during the cleanup, UM&M decided'to take' advantage of the opportunity and perform a general cleanup of the fuel pool They proceeded to cleanup the miscellaneous material foun . ! Description of the Event During the cleanup of the Unit 2 SFP, workers discovered what appeared to be an unused startup source holder tube on the floor-of the spent fuel pool. It was evident by the-shiny appearance that the tube had not been in the core during plant operation and therefore was probably unirradiated. The tube was removed from the floor to a work tabl '
On the morning of September 22, 1992, workers were on the Unit 2 refuel floor completing the final phase of the SFP clean up project. All-irradiated components that were planned to be disposed of had been removed from the SFP and only non-irradiated l materials were being handled. These components consisted mostly .
of poles, lights, J hooks, buckets, and cables. The workers on the refuel floor included two contract waste disposal specialists, two CP&L HP technicians, and one contract HP technicia The contract waste disposal specialist on his own decided to remove what he believed to be an unused Start-up Source Holder (SSH)
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concurrence. The SSH was found.on-the bottom-of the pool:under a support beam, to the east of the fuel pool' gate on or abou _
September 14, 1992. _Between 1000 and 1030 hours0.0119 days <br />0.286 hours <br />0.0017 weeks <br />3.91915e-4 months <br /> on September.22, 1992, with HP coverage, the SSH was raised from the underwater table near the bottom of the pool by the two contract waste disposal specialists. The SSH was lifted by the bottom end (up-side.down). This was not part-of the licensee's procedures. This method of handling sources had been discussed on numerous occasions. Several telephone conversations were held between
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Waste Management-Group, Inc., Chem-Nuclear, Inc., and-licensee
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personnel includi.ng the Chem Nuclear project. coordinator onsit This was the method that had been used to process the Unit I_ *
source holders. Underwater dose' measurements were taken and-due to the low dose rates,-it was decided to remove the SSH from the -
water. Used (irradiated) SSHs previously' handled during this project had measured dose rates as high as 700 R/hr when measure ;
underwate ' The contract waste _ disposal _ specialist-understood that start up
- sources were activated by being irradiated in the reactor core.-
Since this SSH was still shiny, and had low measured dose' rate he'-
assumed that it had not been irradiated. Additionally, when-nothing fell out of the tube 'as it was held upside down, h assumed that if there was a-source, it had already been remove Based on this information' he assumed that there was not a_ source =
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in the SSH, It was noted at time cf removal however, that the SSH '
was bowed, rather than straight. This bowing may have prevented
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- the source from being-dislodged and falling- to the bottom.of the
- fuel poo Additional surveys were performed on the SSH out of-the water. A radiation survey indicated a very small hot spottin the center of the-SSH (about 2 R/hr). The- SSH was " sleeved" in plastic -and
) laced-on the-refuel floor on the. west side of-the SFP. This area lad been set-up as a high contamination work' area. It was not-uncommon for material being removed from the SFP to have hot spots with similar dose rates. On the same morning'(September 22, ;
1992), a pole used to handle filters was found to have a 1.5 R/hr ,
hot spot after removal from the pool. For se"regation and volume reduction reasons, it was decided to cut Uut the. hot section of the SSH, one foot on either side of the identified hot spot. This was also a normal practice. The two-foot hot section would then be placed with the high dose rate waste and tha remaining end sections would be placed with the low dose rate waste. All work was being performed under RWP NO.92-150 Later that day (September 22, 1992), 1500-1530, HP ochnicians prepared the area for making the cut. A high volum, air sample was set up in the breathing zone where the cutting m.s to be performed. Extra plastic was placed on the floor and wet down with a spray foaming agent. The SSH was placed on the floor and
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propped up on one end, lhe sleeved SSH was also wet down with the same foaming agent. Rags soaked in decontamination solution were laid next to the area to be cut, with one of the rags to be held next to the saw blade to catch the cutting Between 1540 and 1550, the contract waste disposal specialist (wearing a full face respirator) made the cut with a porta band sa A licensee HP monitored the work from the south side of the pool, about 15 feet away and up-stream of the ventilation flo He was standing next to a low volume air sampler that .had been
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placed in service for area monitorin When the cut was complete, the center ? foot long piece of tubing was placed in a 55 gallon drum that contained other high dose rate _
material. The ends of the twc 5 feet outside-pieces of tubing were taped and they were 'placed on the floor with other low dose
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rate material awaiting disposal. Upon completion of the cut, while the center piece of tube was lifted, the licensee HP thought he saw something like a small- tube-sticking out of the end of the 3/4 inch SSH tub Since he was: about 15 feet .away, he could m'
make a positive observation, The contractor, while moving the 2 foot section of tubing did not see anything inside,'or sticking out of, the 3/4 inch tube.
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A licensee HP technician began a survey of the work area. The t contractor HP technician and another licensee HP technician checked the work area smears.and masslin cloths with the RM 14/HP-210 instrument in the refuel floor frisking booth. Atter-being informed of high contamination levels-in the work area, a licensee HP technician checked the contractor's outer shoe covcis for contamination. When the results showed that the outer shoe covers were highly contaminated, the licensee HP technician requested the contract waste disposal. specialist remove the outer =
shoe covers to minimize the spread of contamination. The contractor frisked and did not show any contamination prior to exiting the area. One smear in the area where the SSH was cut
showed about 0.32 mrad (about 500,000 DPM/100 cm ) of beta-ga;ama contamination. Due to the high levels of_ contamination, the '
licenser HF technician performed a quick. Feliminary deccniamination of the work area. Between 1700 and 1715, another licensee HP technician and two plant decontamination oersonnel ,
then entered the area to complete the clean-up. The ..rst licensee HP left the area about this time A general decontamination and clean-up of the work area was the normal-routine at the end of each work day. All personnel frisked and found no contamination using the RM-14/HP-210 in the refuel floor frisking booth and left the area about 183 .
The high volume air sample taken during the cutting was analyzed during the night shift and showed a calculated 0.001 maximum permissible concentration (MPC). Am-241 was not included in the-MPC calculation because Am-241 was not in the computer's library for determining MPCs. The computer printout showed 1.57 E-8
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uti/ml Am-241 (which is about 157 MPCs). The low volume air sample taken near the step off pad showed _8.6 E-10 uCi/ml of Am-241 (which is about 3.7 MPCs). This information went unnoticed by the count room personne The next morning, September 23, 1992,- the HP technicians discussed
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the previous days work and were concerned about-the high contamination levels. They had not experienced such high levels of contamination during-this project when other material had been cut _up. Additionally, a licensee HP technician remembered that some start-up' sources contained Am-241. The HP technicians L decided to re-survey the area and have the smears counted 2 for i
alpha contamination. The results showed 230 dpm/100 cm at the
step off pad and 19,000 dpm/100 cm in the work area where the -
tube was cut. -It was then that they reviewed the air sample results, found the Am-241 results, and notified their supervision
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of their findings and concern Alpha contamination surveys were performed in the stairwells to the-Unit 2 refuel floor, the clean areas of the refuel floor, and the high traffic areas between the refuel floor and the Single2 Point Acces Except for two areas on 20' (4 bPh/100 cm each),
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and one spot on 80 foot west (3 DPM/100 cm') the contamination was isolated on the Unit 2117 foot refueling floor elevation. The areas on the 117 foot elevation that were previously designated as non-contaminated had alpha contamination ranging from less than
minimal detectable activity (MDA) to almost 1000 DPM/100cm . The highest contamination was found in the ventilation flowpath- from the area where the-SSH was cut. The work area on 117 foot '
elevation that was previously posted as contaminated had alpha contamination from less that 650 DPM/100 cm' to as high as 19,000 DPM/100 cm2 ,
The surface and .irborne contamination resulted in two of the -
involved workers becoming contaminated. One of the HP technicians and one of the decontamination personnel were found _to have small amounts of contamination on their personal clothing ranging from ,
20 CPM to 2000 CPM as measured with an alpha survey instrument.
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Surveys were performed in the homes and automobiles of the involved individuals. Extensive surveys were performed using ,
smears, plant alpha survey instruments and a survey instrument '
previded by the NRC. No contamination was found in the homes or i automobile .
An extensive bioassay and whole body counting (WBC) program was begun on the six individuals considered most at risk for internal contamination. This group included the contractor waste disposal specialist, t :e three HP. technicians, and the two decontamination personnel who entered the contaminated area about I hour after the event. Arrangements were made with the Genersl Electric ruel Fabrication Facility in Wilmington, NC to perform WBCs on the individuals. The GE equipment was not calibrated to determine quantitatively the amount of Am-241, but could be used to qualitatively determine the presence of Am-241. The initial results showed positive results for two HP technicians; however, af ter showering the analysis showed only one potential internal '
contamination. This finding was further confirmed when the WBC data was reanalyzed using spectrum stripping techniques by ;
Canberra, In ~
Biological (urine and fecal) samples were collected from the workers. The samples were shipped to an independent consulting cmpany for analysi In addition, all of these individuals received WBCs at Nuclear-Fuel Services, Inc., this WBC was calibrated for Am-24 The--
analysis showed one HP techniciari with a trace amount of Am-241 in the lungs. A followup WBC was pertormed on the individual with the uptake and again indicated a trace amount of Am-241 in.the- ,
lungs. Four additional individuals were identified to have been on the refuel- floor during the cutting of the-SSH. These individuals were performing maintenance activities on the overhead-Q
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-crane. All of-the-results'of the_.WBC and bioassay are tabulated .
in Table 2 (Attachment B).- 1 The inspector reviewed the-licensee's Draft Dosimetty Technical Report 9210 titled " Internal Dose Assessment Am-241--Incident,"'
dated October 23, 1992. The assumptions, method of calculation -
and dose estimate appear reasonabl The preliminary results of the licensee's dose calculation for the individuals most at risk are tabulated below:
Preliminary Internal Dose Estimates Intake DCF"' DCF 50 yr 50 yr 1st Year i2 l-(n C1) Bone Effective CDE ' CEDE Effective -
Surface mrem /uci (rem) (rem) Dose mrem /uci (rem) -
- Contract HP 0.41 8.14E3- 4.44E2 .2 0.006 Tech CP&L HP Tech 0.38 -8.14E3 4.44E2- 3 .1 - .006
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CP&L HP Tech .14E3 4.44E2 36 .066 2nd Analysis .14E3 4.44E2 52 .096 NOTE: 1) DCF - Dose conversion factor L 2) _ CDE = Committed Dose Equivalent Organ 3) CEDE - Committe1 Ef fective Dose Equivalent Whole Body The intake for all individuals involved in_ the. event were below regulatory _ limits- for insoluble Am-24 A small amount of Am-241' was released through the monitored -
Reactor Building roof ven The filter on the Reactor Building _
roof vent had been changed on~ the morning of September 22,1992, prior to the event. This filter had also been changed!on
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September 23, 1992, after the event and analyzed for Am-241'.
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Offsite doses were calculated using GASPAR, the computer program used by CP&L!s Offsite Dose Calculation Manual-(ODCM). The maximum offsite dose was calculated to be less than 3% of the-particulate quarterly limit of- 15 mrem /Qtr.
L: Recovery l_
E . Efforts to contain and'. isolate the contamination began-immedi ately.- Surveys were performed.in the lunch room, plant entrance, and the U2-refuel floor to-determine the potential scope- ,
l of contamination. The area behind the ventilation room on the
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15 q 80 foot level showed low levels of alpha contamination'. The ducts -
from the room are under positive pressure and contamination' leaks
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outward onto the 80 foot elevation. Frequent surveying and '
-decontamination of the small area on the 80 foot elevation had been done to prevent contamination from spreading. The filter from the continuous air monitor (CAM)-on the refuel floor was analyzed. This filter was placed in service after the event- at 0023 and removed at 1730 on September 23, 1992. The analysis'
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showed that there was no airborne contamination in the area-following the event. A. neutron survey was performed.on the refuel floor and no neutron radiation was detected except for' about 45 :
mrem /hr on contact with the 55 gallon drum containing .the Am-241 -
sourc .
The initial decontamination and surveys of the previously unposted areas on the refuel floor were complete by 1230 on September 23, 1992. Before beginning to decontaminate the more highly .
contaminated work area of the refuel floor, the equipment hatch and stairwells were covered to prevent spreading contaminatio Additionally, a RC access point was set up on the 98 foot elevation to assure positive control of the refuel floor. This central point was equipped with video monitors, alpha survey o instruments for frisking and a system for counting smer s for alpha contaminatio The major decontamination effort was begun by a contractor that '
was already onsite on September 27, 1992. A decontamination engineer was added to the onsite decontamination team staff to provide additional guidance for the recover The primary method employed for decontaminating the refuel floor general area was 'a strippable latex. coatings. Other areas (overhead crane, catwalks, refueling bridge. -etc.) have required manual (vacuum cleaners and wipes) decontamination'. Portions of the overhead-crane have a heavy film of grease and oil.. This cleaginous condition prevented the typical migration often associated with alpha contamination. Since.the alpha particles are captured within the grease and oil, this equipment-must have a complete cleaning using a solvent. The decontamination effort was hampered by the necessity to remove a large amount of reusable and non-reusable material from the refuel floo On September 29, 1992, a matrix management team was' assembled to facilitate the decontamination effort. The team included:
Project Manager i
OM/M (Refuel floor)
OM/M (Plant Services)
Maintenance Operation (Contact)
Technical Support ALARA
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Radwaste-$ hipping-Stores Results of the team actions have not been accessed since:the recovery effort is still-underwa The inspector reviewed the Am-241 clean up efforts that the licensee had in progress. The floor and walls of the 117 foot level of the unit 2 refueling floor had been coated with a strippable latex paint to contain, tra), and therebyLimmobilize the alpha contamination. Removal of t1e paint had not yet begu A schedule for paint removal has been developed and the paint removal should be complete by the end of December. The paint removal was to follow the overhead beam and su) port decontamination. Areas are being cleaned to tie release limit for-uncontrolled access of <20 0PM/100 cm'.
The inspector voiced a concern about alpha contamination that had--
been deposited in the. refueling floor ventilation duct work- and fan ventilation system. The licensee has developed a plan to address this issue and is currently evaluating the alternative The inspector informed the iicensee that the ventilation system cleanup would be tracked as an Inspector' Followup Item (IFI).
IFI 50-325, 324/92-32-02: Review Unit 2 ventilation system actions associated with recovery from the September 22, 1992-Am-241 even The licensee has retained a consultant, experienced-in alpha contamination and dose measurements, -The consultant visited the site on October 8-9, 1992, to review data, interview personnel, and to tour'the refuel ticor. .The _ final report w'as not available for review during the inspectio ~
After reviewing the seq'uence of eventsLand the actions taken:by the licensee, the inspector informed the licensee that there were-two apparent violations associated with the event. . The iirst violation-. involved a violation of-10 CFR 20.203f f) for- failure to label a container ~of licensed radioactive material. The regulations provide ~ the exceptions:that: containers -in 1ocations such as water-filled canals in lieu of a durable clearly visible
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label identifying the. radioactive. contents.shall. be provided a readily available written record. ;It was evident- that this record -
, failed to exist and the 5.38 Ci (5.4 Ci) source (Am-241) had been placed in the pool and stored there since 1978 without this recor The inspecto'r noted that.IR 50-325, 324/91-20_ indicated that--the-following NRC. ins had been received by the licensee, -reviewed for -
applicability, distributed to appropriate personnel, and that '
actions as'appropr.iate were taken or scheduled. .
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IN 90-47,' dated July 27, 1990, . Unplanned Radiation Exposure to Personnel Extremity Dose to Improper Handling;of- *
Potentially Highly Radioactive Sources ;
- IN 90-33, dated May 9, 1990, Sources of Unexpected .
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Occupational Radiation Exposure at: Spent Fuel Storage Pools The licensee in response to IN 90-33 developed Procedure Al-ll2 titled " Control of Materials in the Spent Fuel Pool" which states that "The purpose of the procedure is to control the-types of materials and movement of materials in the spent fuci pool."
These materials include special nuclear materials (neutron detectors, fuel, etc.) and highly irradiated hardware / materials, which if removed would pose a significant radiological concer (i .e. , radiation exposure and potential . airborne contaminations)'."
Step 3.3.6 of Al-112 stat it materials placed into, removed from, or relocated in ti1e . at fuel pool are to be documented on Attachment A. Attachment A is to be forwarded to Nuclear Engineering to facilitate spent fuel pool cleanup efforts and waste characterizations requirements. This was not done in the case of the Am-241 sourc '
The failure of the licensee to provide a readily available written record identifying the Am-241 source and its storage location in the pool was identified as an apparent violation of regulatory requirement Violation 50-325,324/92-32-03: Failure to provide a readil available written record for the 5.4 Ci Am 241 source as required by 10 CFR 20.203(f).
The second violation involves the failure to perform adequate surveys to evaluate the extent of radioactive hazards that were-present prior to cutting the source holder. The waste disposal specialist removed the Am-241 source without technical evaluation or project concurrence. The SSH was not on the U-2. Fuel Pool-Inventory performed on February 11, 1992, and was'not part of the
- work scoae. The SSH was found on the bottom of the pool under a support ]eam, to the east-of the fuel pool gate on/about September 14, 1992. The SSH was removed from the SFP during the morning of September 22, 1992. The SSH was ' sleeved in plastic an_d t readied for cutting about 1500 hours0.0174 days <br />0.417 hours <br />0.00248 weeks <br />5.7075e-4 months <br /> on September 22, 1992. __At no-time was a technical evaluation of the SSH performed to determine whether it in fact contained a source, and if so, its location in the tube and necessary radiological precautions prior to cutting-the SSH. This was identified as an apparent violation of 10 CFR 20.201(b).
Violation 50-325,324/92-32-04: Failure to perform adequate surveys to evaluate the extent of radioactive hazards that were present prior to cutting the source holder as required by 10 CFR 20.201(b).
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1 Exit Meeting (83750) (92702) 'l
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'l The inspector met with-licensee representatives indicated in Paragraph 1 )
at the conclusion of the inspection on September:28, 1992, October 30, i 1992, and by-telephone on November 12, 1992. The inspector summarized- l the scope and findings of the inspection. The inspector also discussed l the likely information content of the report with regard to documents or i processes reviewed during the inspections. The licensee did_not l identi_fy any such documents or processes as proprietar Dissenting- ;
comments were not received from the license '
Item Number Description and Reference 50-325,324/92-32-01 VIO - Failure to follow E&RC Procedure 0230, Rev. 25 (Paragraph 5.a).
50-325,324/92-32-02 IFI - Review Unit 2 Ventilation System actions associated with recovery from the September 22, 1992 Am 241 event (Paragraph 8.c).
50-325, 324/92 32-03 VIO Failure to provide a readily available written record for the 5.4 Ci Am-214 source as required by 10 CFR 20,203(f) (Paragraph 8.c).
50-325,324/92-32-04 VIO - Failure to perform adequate surveys to evaluate the extent of radioactive hazards that were present prior to cutting the source holder as required by 10 CFR 20,201(b)
(Paragraph 8.c).
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ATTACIEY23T A TABIE 1
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JLRUNSWIC1LJJ.QQhEAR PLAliT MONTMLY BACKGROUND VALUES, REACTOR POWER, AND HYDROGEN WATER CHEMISTRY INJECTION RATES 1991 DATA
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H H El M REACTOR HWC POWER % - INJECT.--
U/1 U/2 _ RATE s
PAP 3 .3 2 .4 0 100_ 8.8-6.0 U/2 SAP 3 .8 2 .5
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FEB PAP 4 .7 3 .8 8-36 100 7.0-11.0 U/2 SAP 36.1 _
3 .9 2 KAR PAP 5 .0 4 .3 100 100 1 U/2 BAP 4 .3 3 .3 ;
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APR PAP 1 .2 1 .5 0 100 NONE SAP 2 .5 1 .4 MAY PAP 2 .2 1 .1 100 100 NONE SAP 2 .7 1 .5 l
JUN PAP 3 .0 2 .9 100 100 8.05U1 8.0U2 l SAP 3 .5 2 '( 9 .1 *** )
- INTcr104 BD3AN 6/20 FOR BCrn! UNITS l l
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Il M M M REACTOR HWC -
POWER 4 INJEC U/1 U/2 RATE JUL 3 .1 2 .8 100 100 NONE PAP BAP 3 .1 2 .3 AUG 4 .4 2 NONE-PAP 4 SAP _ 4 .2 3 .4 REF PAP 5 .7 3 .7 100 90 NONE BAP 4 .6 ,3 .5 OCT ,
PAP 1 .2 1 .4 100 70-50 NONE SAP 1 _
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PAP 2 .7 1 L4.o_ 100 50-30 NONE SAP 2 .0 1 .6
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DEC 3 .5 1 .2 100 30-0 NONE PAP SAP 3 .4 2 .0 _ .a -- ..._
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TABLE 2 ATTACHMENT B QUALITATIVE AM-241 INDICATIONS October 26. 1992 Contract Licensee Licensee Contract Contract' Contract Waste HP HP HP Decon Decon Disposal Specialist 1st Count on GE Negative Positive Positive Negative Negative Negative Lung Counter 2nd Count on GE N/A Positive Negative N/A N/A N/A lung Counter -
Following Shower Canberra Analysis Positive Positivt Positive Negative Negative Negative of GE Counts 1st fecal Sample Negative Positive Positive Positive Negative N/A Geli Scan 1st fetal Sample Negative Negative Positive -sitive Negative N/A CEP Result 2nd fecal Sample Negative Negative Negative Negative Negative N/A GeLi Scan 2nd fecal Sample Negative Negative Positive Negative Negative N/A CEP Result
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3rd fecal Sample N/A Negative Negative N/A~ N/A N/A Geli Scan 3rd Fecal Sample N/A Negative Negative N/A N/A N/A CEP Result 1st Urine Sample Negative Negative Negative Negative Negative Negative GeLi Scan 1st Urine Sample Negative Negative Negative Nh ative Negative Negative CEP Result 2nd Urine Sample Negative Negative Negative Negative Negative Negativa Geli Scan 2nd Urine Sample Negative Negative Negative Negative Negative Negative CEP Result
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Clothing Survey N/A Positive N/A Negative Positive Negative "
lst Car Survey Negative Negat b Negative Negative N/A N/A 2nd Car Survey Negative NegatuT Negative Negative N/A N/A ist Home Survey N/A Negative Negative N/A Negative _N/A 2nd Home Survey N/A Negative Negative N/A Negative N/A NFS Negative Positive Negative Negative Negative NegativF NFS Recount N/A Positive N/A N/A N/A N/A
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