IR 05000333/1989013

Insp Rept 50-333/89-13 on 890613-15.Violations Noted.Major Areas Inspected:Circumstances,Evaluations & Corrective Actions Re 890612 Unplanned Exposure of Individuals Working in Close Proximity to Highly Radioactive Object

ML20248A595
Person / Time
Site:	FitzPatrick
Issue date:	08/02/1989
From:	Nimitz R, Pasciak W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:
Shared Package
ML20248A587	List: IR 05000333/1989013 ML20248A583 ML20248A589
References
50-333-89-13, NUDOCS 8908080342
Download: ML20248A595 (11)

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U.S. NUCIEAR RDITIATORY CCH4ISSION

REGION I

Report N /89-13 Docket N License No. DPR-59 Priority -

Category C Licensee: Ptwe.r Authority of the State of New York P.O. Box 41 Iyconung, New York 13093 Facility Name: James A. FitzPatrick Nuclear Power Plant Inspection At: Lycoming, New York Inspection Corducted: June 13-15, 1989 Inspectors: Mir & #!2/M R. L. Nimitz, Senior Radiation Specialist 'date

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Approved by: s %h a f M W. Pasciak,\ Cplef, Fpilities Radiation ' dhte '

Protection s6ction Inspection Summary: NRC Inspection No. 50-333/89-13 performed on June 13-15, 1989 Areas Inspected: 'Ihis inspection was a special announced radiological controls inspection to review the circumstances, evaluations and corrective action associated with the unplanned exposure of several individuals who worked in close proximity to a highly radioactive object fourd in the strainer area of the Spen' niel Storage Pool on June 12, 198 Results: One apparent violation of NRC requirements was identified (Failure to perform surveys in accordance with 10 CFR 20.201; Details Section 7).

Several weaknesses were also identified in the oversight and control of on-going work on the Refueling Floo "

8908080342 890802 PDR ADOCK 05000333 Q PDC

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'b Details 1.0 Individuals Contacted 1.1 New York Power Authority

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• Fernandez, Resident Manager

• Liseno, Superintendent of Power

• Johnson, Assistant Operation Superintendent

• Mulcahey, Radiological and Envinuuud;21 Services Supervisor

• Bergene, AIARA Supervisor

• Vargo, Radiological Engineering General Supervisor

• J. Solini, Health Ihysics General Supervisor

• D. IdJdsey, Planning Superintendent

• J. McCarty, Radiation Protection Supervisor A *K. Phy, Refuel Floor Supervisor 1.2 NRC

• R. Plasse, NRC Resident Inspector

• Denotes those individuals attendirg the exit neetirg on June 15, 198 'Ib inspector also contacted other licensee and contractor personne .0 Purpose ard Scope of Inspection

'Ihis inspection was an announced special radiological controls inspection to review the circumstances, evaluations, and corrective actions associated with the unplanned exposure of several individuals who worked in close proximity to a highly radioactive object in the strainer area of the Spent Fuel Storage Pool Skimner on June 12, 198 Radiation fields emanatirg from the object caused the pocket dosimeters of one of the individuals to go off scale {>500 millirem whole body dose).

3.0 Description of Event

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3.1 Backgrourd

'Ihe licensee has been cleanirg up the Spent Fuel Storage Ibol over the past several years. The clean-up involves cuttlig up highly radioactive vacuumiry of the floor of the material Spent Fuel(e.g. usedPool, Storage control rod blades),ial

,reckagirg mater in preparation for shipment, ard shipping of the packaged material to a licensed burial grourd. 'Ihe majority of this work is done urderwater using remote tool .

The licensee experienced same problems with Spent Fuel Storage Pool work in February 1987 (Reference NRC Report No. 50-333/87-07). At that time en individual sustained an overexposure of an extremity when haMling material that was not surveyed properly when the material was removed frun the Spent Fuel Storage Pool. In response to the overexposure event, the licensee enhanced radiological controls for on-going Spent Fuel Storage Pool wor During this inspection, the inspector also reviewed the implementation of the corrective actions for the February 1987 overexposure even (Reference New York Power Authority Intter, No. JPN-87-028, dated May 21, 1987). The purpose of the review was to ensure all corrective actions described in the licensee's letter were implemente .2 Specifics At about 4:30 p.m. on June 12, 1989 three contractor workers signed in on Radiction Work Permit No. 89-1536-S, " Pick-up Boron Tubes / General Cleanup." Two of the contractors (Individuals A and B) set up the r-mry support equipment to perform underwater dose rate measurements on equipment and material to be removed from the Spent Fuel Storage Poo The set-up of equipnent involved moving lighting and underwater survey meter probes. The third contractor mopped the Refueling Floor. The two cor. tractors (Individuals A and B) perfo . work around the Spent Fuel Storage Pool were not provided alarming dos . ters. The contractor (Individual C) mopping the floor was provided an alarming dosimeter. The individuals had atterded a pre-work briefing at about 3:30 p.m. On June 12, 1989. Planned work activities for the shift were rHe At about 4:45 p.m. on June 12, 1989 the two contractors (Individual A and B) performed a dose rate measi;ueuent of a bracket. The measurement was performed without inciden During the period 5:00 p.m. to about 5:45 p.m. on June 12, 1989, the two contractors (Inlividual A and B) set up and moved several spent vacutun cleaner filters. The filters were noved to a flow channel rack. Because the contractors were experiencing difficulty in uprighting the filters, the contractors used underwater hooks to upright filters. The uprighting was performed during the period 5:45 p.m. to about 6:10 p.m. on June 12, 1989. The uprighting was n-vry to perform dose rate wasurements on the sides of the filters. These measurements are used to determine, in-part, the curie content of each filte At about 6:10 p.m. on June 12, 1989, a contractor radiation protection technician (Individual D) was requested to perform a survey of the underwater hook used to upright the filters. The hook was being removed by individuals A and _ _

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When the radiation protection technician (Individual D) arrived, he performed a survey of the hook as it was removed. W e technician (Individual D) noted a reading of about 300 millirenVhr on a joint of the underwater hook. Surveys of the hook ard area near the hook by the radiation prutection technician indicated that tic radiation dose rates were condng frun the general area of the northeast corner of the Spent Fuel Storage Fool he northeast corner exhibited a general area dose rate of about 5,000 millirenVhr. At that time, about 6:10 p.m. on June 12, 1989, the radiation protection technician the area ard requested personnel to check their(Individual pocket dosimeter D) evacuated We contractor's (Individuals A, B and C) 0-500 millirem pocket dcsimeters indicated off scale, about 360 millirun, and 80 millirem respectively. We radiation protection technician's (Individual D)

dosimeter indicated 40 millire We radiation prutection technician (Individual D) checked tha northeast corner and located a dose rate of about 260 rem /hr in the area of the Spent Fuel Pool Skimmer. W is dose rate was located at the water level about one foot below the level of the Refueling Floo 'Ihe Spent Fuel Storage Pool operations were innediately halted and licensee management was informed of the even .0 Notification to the NRC me inspector reviewed the notification of the event made by the licensee relative to reportincJ requirements contained in 10 CFR 20,10 CFR 50, and Technical Specification 'Ihe inspector concluded that the event was not required to be reporte We licensee did make a courtesy notification of the event to the IEC resident inspector who subsequently notified IRC Region I managemen No violations were identifie .0 Dose Assessment

'Ibe inspector reviewed the dose --nts performed by the licensee for the individuals involved in the event. h e inspuctor evaluated the

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adequacy of the licensee's dose awent by dimwions with personnel, by making ind ent radiation dose rate measurements of the area, and by performing time and notion sttriies for the involved individuals. We r also reviewed the adegaacy of supplied dosimetr __ ___ _ _ - _ - _

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Wee the object ormhma non-uniform radiation dose rates arxi the individuals wore tr.eir dosimetry on their chests, the licensee perforrni i a time ard notion study for the individuals to determine the doses i received by other portions of the body. % e lower portions of the body 1 had the potential to have sustained a higher dose than that indicated by j the chest TLD body and pocket dosimete l W e inspector considered the licensee's dose assessment to be reasonabl W e highest whole body exposure was received by the individual whose dosimeter went off scale. 'Ihis individual received 780 millirem whole body and 960 millirem to the extremity raisirg his quarterly total to 1450 millirem whole body and 1630 millirem extremity exposure. Wese ,

exposures do not exceed the NRC limits, f l

No violations were identifie .0 Training The inspector reviewed the trainirg and qualifications of contractor )

personnel involved in the June 12, 1989 even %e inspector review irdicated the contractors irrsolved (Individuals A, I B, C arxi D) had been provided appropriate radiatian worker training. We inspector also detenuned that the procedurally required pre-work briefing had been held prior to start of the work. 'Ihis briefing was I held at 3:30 p.m. on June 12, 1989 ard included a discussion cf planned i work activities. The contractors were aware of radiological hazards with the material they were handlir ,

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'Ihe inspector reviewed the training and qualifications of the contractor i radiation protection technician (Irxiividual D) who provided radiological coverage of the work. We inspector detennned that the individual met i Technical Specification qualification requirements. 'Ihe individual had also been trained and tested in accordance with the licensee's qualification progra W e inspector found, however, that when the contractor radiation protection technician was oricyinally hired on March 25, 1989, the contractor did not meet the nunimum licensee qualification requirements to be considered a Senior Radiation Protection Technician. 'Ihis is because the individual ,memcen! Navy experience which the licensee's qualification procedure required to be ruhma by a certain amount. We reduction would result in the individual not meeting minimum qualification requirements to be considered a Senior Radiation Protection Technicia _ _ - _ _ _ _ _

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l 6 However, licensee radiation protection management perronnel authorized the individual to be considered a Senior Radiation Protection Technicia The inspector's independent review indicated that the individual did meet NRC requirements to be consbered a Senior Radiation Protection Technician when the individtal was hired. The inspe-ctor noted that the licensee's approved personnel selection and qualification procedures requirements were not adhered to when evaluating the qualifications of the contractor. The licensee's radiation protection management indicated this was an oversigh The licensee's corrective actions for this matter are dire' W in section 8 of this repor .0 Radiological Controls The inspector performed an independent review of the adequacy and effectiveness of the radiolocJi cal controls provided for the Spent Fuel Storage Pool clean-up operatio The inspector's evaluation was based on independent review of documentation and log books associated with the work, discussions with perrennel, independent tours and review of the Spent Fuel Storage Pool area, and performance of independent radiation survey measurement The following matters were reviewed:

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adequacy of and adherence to radiation work permits used to conul the Spent Fuel Storage Pool clean-up operations

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establishment and implementation of appropriate procedure 1:-

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adequacy of radiological surveys performed during the clean-g>

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adequacy of Hot Particle controls

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supply and use of dosimetry including integrating alarming dosimetry

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use of portable area radiation monitors

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use and adequacy of protective clothing Within the scope of this review, one apparent violation was identified:

10 CFR 20.201, Surveys, requires in section (b) that each licensee shall make or cause to be made such survey as (1) may be necessary for the licensoe to comply with the regulations in 10 CFR Part 20, and (2) are reasonable under the cirtunstances to evaluate the extent of radiation hazards that may be presca CFR 20.201 (a) defines, in part, a survey as an evaluation of the radiation hazards incident to the presence of radioactive material When appropriate, such evaluation includes a physical survey of the location of material and equipment, and reasurunents of levels of radiation presen ,

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I me inspector determined that a pre-job radiation survey of the general ]

work area (northeast corner of the Spent Fuel Storage Pool) was performed  !

at about 4:45 p.m. on June 12, 1989. 'Ihis radiation survey iniicated I normal general ama radiation levels (2-3 milliratVhr). {

i Between 4:45 p.m. June 12,1989 and 6:00 p.m. on June 12, 1989 two j contractors (Individuals A ard B) performed various work activities in l

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the Spent Fuel Storage Pool, includirg using underwater toole to pick up Bomn 2bes on the floor, moving lightirg, pickire up ard setting up-right underwater vacuum filters, placing underwater vacuum filters on fuel channel racks, ard perfornirg dose rate meastuusad Unknown to the two contractor workers (Irdividual A and B), during the period a highly radioactive object (estimated to be 1000 rutVhr on 4 contact) appeared in their work area. This source pr@ma dose rates to various parts of the whole body of betwoon 1000 millirenVhr to about 4700 millirenVh During this time period (4:45 p.m. to 6:00 on June 12, 1989), the radiation protection technician (Irdividual D) assigned to cover the Spent Fuel Storage Pool work was on standl waiting in a low dose rate waiting area. At ne time durirg this perlu did he check dose rates in the work are At about 6:00 p.m. on June 12, 1989 the radiation protection technician (Irdividual D) was called to the work area (northeast corner of the Spent Fuel Storage Pool) to check a tool for removal frun the Spent Fuel Storage Pool. At that tire he discovered general radiation fields of about 300 millirenVhr ard contact dose rates up to 260 int /hr near the Spent Fuel Storage Pool Skimme me inspector concluded that the radiological surveys provided durirg the period 4:45 p.m. to 6:00 p.m. on June 12, 1989 were inadequate to detect the presence of the highly radioactive object that appeared in the contractor's work ama. The failum to provide adequate radiation surveys during the work is an apparent violation of 10 CFR 20.201(b)

(50-333/89-13-01).

We inspectar also determined the followirg:

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The area radiation ronitor (AIN) on the refuelirg bridge, which was in the work area, was malfunctionirs. It was determined to be Inadini low by 80% (i.e. , it indicated only 20% of the actual radiation field ). mis monitor had been calibration checked in September 1988. Sem were no routine operability checks made of the monitor since that tim _ _ _ - _ - _ _ _ - -

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Although two wall mourtwd AIMS were on the north and east walls of I the Refueling Floor, it was unlikely, considering geometry, that  !

they could detect the radiation frcan a highly radioactive small object, floating an the surface of the pool. The detector did not i detect any significant radiation field increase caused by the 1000 rerr/hr objec There were no supplemental ARMS installed for the work. These AIMS woul.1 give an indication of general area radiation fields near the work are The two contractors (Individuals A and B) performing the work were not provided integrating alarming dosimeter The radiation work permit providing ccatrols for the work (IMP N ) did not provide a set frequency ror performing general area radiation survey The contractors (Individuals A and B) did not routinely check their pocket dosimeters for accumulated dose because their dosimeters were urder their protective clothing. No lenental dosimeters were provided. The IMP did not contain requ ts for checking pocket dosimeters during work. (Note: Individual A's dosimeters went off-scale durirg the work.)

The licensee's corrective actions for the above matters are rHmmW in section 8 of this repor The follcwing other matters were brought to the licensee's attention:

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The licensee used different terminology on the IMP when referring to equipnent to be surveyed when renoved from the Spent Fuel Storage Pool as campared to the terminology used in guxdares. It was unclear as to what was to be surveyed when recoved from the Spent Fuel Storage Poo The inspector observed personnel pass material across a Hot Particle Zone barrier without surveying the material. Procedures provided limited guidance for Hot Particle control The ALARA review for the clean-up of the Spent Ibel Storage Pool (d$1ted February 15, 1989) did not address potential radiological hazards associated with charging out of vacuum cleaner filters or handling the filters unierwatem The inspector noted that the filters released various sized clouds of dirt underwater when i

filters were changed out and handled. In addition one filter was

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crushed during hardling on June 12, 1989 prior to the identification of the highly radioactive object.

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On April 18, 1989 pieces of a broken bucket floated to tha surface of the Spent Fuel Storage Pool. h pieces maamtred up' to 500 millirw Vhr on contact. An AIARA revi s of the radiological significance of the floating pieces was not made. [ Note: Ihe licensee's preliminary review indicates that the obJ ect was a Hot Particle attached to a piece of broken bucket that floated to the surface during the work activities on June 12, 1989.)

Licensee corrective actions for the above matters are d%=d in section . Management and Supervisory Oversight i The inspector reviewed the supervisory and management oversight of the Spent niel Storage Pool clean-up operation The following was noted:

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Licensee approved procedures provided clear descriptions of personnel responsibilities and authorities for the Spent Fuel Storage Pool wor i

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One licensee individual was delegated as the Refueling Floor supervisor throughout the operation The following matters were brought to the licensee's attention: i

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Ihe inspector observed several exanples of poor cudmuination i cuiwl (e.g., passing objects out of a Hot Particle Zone) . The observation indicated lack of attention to detail by puhuel and weak supervisory oversigh The licensee established a standing orderi M itled " Supervisory )

Oversight of Radiol ical Work", DS0-08. Liis order provides good i guidance for perfo oversight of radiological sensitive work activities. Although no clear frequencies for performances of suc l oversight is provided, it does indicate that supervisors and !

mana will perform periodic reviews of sensitive jobs. The order the cartpletion of a Radiological Review Form contained in the order. The performance of these reviews per the licensee's' l order was highlighted in the licensee's response to the February 1987 extremity overexposure event as a means to inprove supervisory '

oversight of work activities (Reference the licensee's May 21, 1987,-

letter to NRC, JPN-87-028) .

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Inspector review indicated no reviews were dmmanted for the past two and a half months by licensee supervisors of the Spent Fuel Storage Pool work, a radiologically sensitive work activit Contractors involved in the work, however, had documented reviews of their own work. The failure to ir.plement self review process is considered a weakness.

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! Corrective Actions  !

In.s p e M w ions with licensee personnel indicated the highly radioactive object identified at the Spent W el Storage Pool Skimmer area was a Hot Particle omhwMed in a piece of plastic bucket. Se object and piece of bucket had apparently been released during handlirg of underwe.ter vacuum filters or may have been released during hardlirg of ;

other undervater equignen Se inspector met with the licensee's representatives on June 15, 198 Se licensee's representatives indicated the following actions would be ,

taken prior to resumption of Spent Fuel Storage Pool clean-up operation !

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A comprehensive radiological survey of the Spent Fuel Storage Pool area ard Spent Fuel Pool Clean-up System would be performed to locate any other potential highly radioactive object Procedures would be issued or revised to address clean-up of the pool debris that could float. Procedures also would be revised to clarify requirements for survey of materials to be removed from the ,

Spent mel Storage Poo Radiological Controls would be upgraded to require personnel to wear alarming dosineters when workirg arourd the pool or that portable

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area radiation ronitors be provided to monitor radiation dose rates arourd the Spent Fuel Storage Poo me licensee will provide enhanced supervisory oversight of the Spent Fuel Storage Pool operation Perr.m nel involved in pool clean-up activities will be provided trainiry on the event and appropriate revised procedure ;

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Access to the Spent Fuel Pool Clean-up System will be strictly Mulled pendirg performance of radiation surveys of the system to j identify any highly radioactive pieces. Also, an evaluation to !

determine the radiological haza7ds associated with general access to the system will be mad ,

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2e licensee will develop ard duplement enhanced sucslures for Hot Particle controls for personnel workirq crourd the Spent Fuel Storage Pool ard renovire articles from the poo m e quality assurance group will be directed to perform an audit of Spent Fuel Storage Pool clean-up operations to ensure previous IEC commitments have been implemente An evaluation of the lack of response of the Spent Fuel Storage Pool bridge radiation ronitor will be performe _ _ ____ __ _ __ m

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An evaluation will be performed of the selection criteria for l radiation protection technicians.

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Appropriate dose as-e will be made for all personml involved l in the event.

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The limnsee issued a special procedure (70P-101) for retrieval cf the j object. The inspector observed preparations for the mtrieval. The retrieval was performed in a radiological safe manner. The individual who retrieved the object with a long haniled tool and placed it in a lead shield received ininimal radiation exposur .0 Exit Meetirn The inspector met with licensee repmsentatives (denoted in Sect. ion 1) at the conclusion of the inspection on June 15, 1989. The inspector summarized the purpose, scope, and firxiings of the inspection. No written material was provided to the licensee.

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