IR 05000333/1990012
| ML20012E648 | |
| Person / Time | |
|---|---|
| Site: | FitzPatrick  |
| Issue date: | 03/22/1990 |
| From: | Chawaga D, Oconnell P, Pasciak W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML20012E647 | List: |
| References | |
| 50-333-90-12, NUDOCS 9004060039 | |
| Download: ML20012E648 (12) | |
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U.S. NUCLEAR REGULATORY C0mlSS10N
REGION I
l Report No.
50 333/90 12 l
Docket No.
50 333
License No.
OPR 59 f
Licensee:
Power Authority of the State of New York KO. Box 41 i
Lycoming, New York 13093 f
facility Name: James A. FitrPatrick Nuclear Power Plant
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Inspection At:
Lycoming, New York l
Inspection Conducted:
March 14 - 15, 1990 Inspectors:
/fL 7 22-h P. O'Connell', Radiation Specialist date 5-21-%O a :1 w
D. chawaga, Rndiation 5pecialist date j
Approved by:
SLN m g h
3 Ilbi b
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W. Pasciak Section E,hlef racilities date'
Radiation krotection hetIon Inspection Summary: Inspection conducted March 14 - 15 1990 i
Finspection Report No. 5073379Fi2 )--
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Areas Inspected:
This inspection was a special reactive ins >ection conducted to review a Mirch 8 1990 personnel contamination incident witch resulted in t
anexposuretotheleftextremityofoneindividual.Theex potential to be in excess of NRC quarterly exposure limits.posure had the
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f The inspectors reviewed the adequacy and effectiveness of the licensee's pre-job planning for I
the work evolution, the circumstances surrounding the event, the corrective
actions planned or taken following the event, the dose evaluation for the i
nonroutineworkactiviliesinvolvingradioactivematerial.programtoconduct contaminated individual and the adequacy of the licensee's
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Results: Within the scope of this inspection two apparent violations and one
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unresolved item were identified. The first apparent violation involved a failure to instruct a worker in :)recautions or procedures to minimize
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exposure as required by 10 CfR 13.
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The second apparent violation involved a failure to prepare and adhere to procedures for operations involving personnel exposure to radioactive material. The unresolved item involved the licensee's final determination of occupational dose to an individual and the adequacy of the dose assessment, in addition, the inspectors identified significant weaknesses in the licensee's overall contamination controls established for work involving the handling of high specific activity liquid radioactive sodium 24 (Na 24).
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Details f
1.0 Individuals Contacted I
1.1 New York Power Authority
- W. Fernandez, Resident Manager
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- R. Liseno, Superintendent of Power
- M. McMahan, Consultant EngineerDosimetry Supervisor
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- S. Porter, i
- G. Re Cor
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- J. Solini,porate Supervisory Radiological Engineer Health Physics General Supervisor
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- G. Vargo, Radiological and Environmental Services Superintendent l
1.2 NRC
- R. Plasse, NRC Resident inspector i
- W. Schmidt, NRC Senior Resident inspector
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- Denotes those individuals attending the exit meeting on March 15, 1990.
The inspectors also contacted other licensee personnel.
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2.0 Purpose and Scope of Inspection l
l This special reactive inspection was conducted to review a contamination
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incident which occurred on March 8, 1990 that resulted in one individual t
receivinganexposuretotheleftextrealtyandtwoadditional
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individuals receiving minor contamination.
The ex>osure had the potential to be in excess of regulatory limits. T1e inspectors reviewed
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the adequacy and effectiveness of the licensee's pre job planning for the i
work evolution, the circumstances surrounding the event, the corrective I
actions taken and planned following the event, the dose evaluation for the contaminated individual, and the adequacy of the licensee's program
to conduct non routine work activities involving radioactive material.
The inspectors evaluated the licensee's performance in the above areas by reviewing applicable documents including procedures, interviewing the
licensee s personnel including the individual who was contaminated touring the areas of the contamination event,ividual's activities.andperform time and motion study of the contaminated ind
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3.0 Description of the Event i
3.1 General
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the licensee initiated a reactor feedwater flow test.
On March 0, 1990,is test procedure was to verify the calibration of the The purpose of th i
feedwater flow monitors. The flow test involved havin and in.iect approximately 240 mci of Sodium 24 (Na 24) g a vendor prepare into the reactor feedwater system. The attached figure 1 depicts the general injection
flow path.
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The injection sequence, as described in procedures involved removing a 4 milliliter (al) capsule containing the Na 24 from a, shielded cask, placing the capsule behind temporary shielding on a work table, removing the capsule cap and placing it in a disposable container,lution in the j
and emptying the contents of the capsule into a mixing beaker. The so
beaker was then to be slowly in.iected into the primary system at about 7 l
cubic centimeters (cc)d placed behind the temporary shielding.The capsule was to i
per minute.
demineralized water an All of
this work was to be conducted by two contractors using long handled
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tools with the licensee's Radiological and Environmental Services (RES)
l Technician providing job coverage.
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i 3.2 Seouence of Events i
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On March 8,ining for tits job evolution.1990, at a
> proximately 11:00 a.m., the licensee conducted the t
mock up tra The mock up training did not
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include the use of a disposable container for the capsule cap as was
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required by the operating procedure, j
proximately 1:00
.m.
on March 8 1990 an ALARA lannin Atakngwasheldfora$1pe,rsonnelinvolvedwiththete!re.$ncludi!gthe
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meet t
RES Technician. TheRESTechnicianwasnotgiveninstruclionsastothe i
disposition of the Na 24 source capsule or cap..
In addition the RES
Technicianwasnotgiveninstructionsastotheproperradiological l
precautions to take while working with this high specific activity j
solution.
r At approximately 4:00 I).m.. on March 8,1990, the RES Technician and the i
two contractors began the job evolution. The two contractors were requiredtowearprotectiveclothinkeswhich consisted of lab coats, tton I
faceshields, cotton and rubber boot and surgeons gloves with co liners.
TheRESTechnician>rovidingthejobcoveragewasnotrequired i
to wear protective clothing >y the Radiation Work Permit l
hedecidedtowearshoecoversandasinglesetofsurgeon(RWPD,however.
s g oves for t
entry into the contaminated work area.
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Using lon handled tools the two contractors removed the capsule from the
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cask and laceditinaIraybehindtheshielding.
They then removed the l
cap and p aced the cap beside the capsule in the tray. The capsule was emptied into the mixing beaker,ician made dose rate measurements with a longrinsed, and p the cap.
The RES Techn handled meter during this evolution. The dose rates were approximately t
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50 R/hr on contact with the full capsule of Na 24.
The contractors wore extremity and whole body dosimetry during this activity. After the capsule
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was emptied and rinsed the dose rate in the general area around the capsule
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was apprcximately 1.5 R/hr. No contact dose r6te readings were taken on
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i the empty capsule and cap. The two contractors then left the area.
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TheRESTechnician,thecaphadbcontaminationsurveyswithdiscsmear while makin noted that en left off the capsule on the tray.
papers $Technicianpickedupthecapwithhisglovedrighthandandput The RE i
the cap back on the capsule.
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The RES Technician completed taking the smears and exited the I
contaminated area at approximately 4:06 p.m.. Apparently,Technicianwhile removing
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his gloves upon exit from the contaminated area the RE5 unknowingly contaminated his left thumb with the, Na 24. The RES
Technician then waited approximately 5 to 10 minutes for an air sampler l
to be brought to the area, set up the air sample then left the area.
in the area so
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There were no personnel contamination monitors (friskers)t to frisk.,At the RES Technician proceeded directly to the control poin t
the control point the RES Technician alarmed the whole body contamination
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monitors at approximately 4:20 p.m..
The RES Technician then attempted f
to survey himself and apparently contaminated a hand held frisker.
Two otherRESpersonnelalthecontrolpointbegansurveyingtheRES Technician. These two individuals subsequently became contaminated b1
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h using the contaminated hand held frisker. The contamination levels er i
these two individuals was at a low level was ouickly removed and did
notresultinsignificantdosetotheseIwoindividualsorreq,uirea i
whole body count.
j Contamination on the RES Technician who picked up the cap of the capsule was I
found on several areas of his person including his hands shoes, chest, l
and thigh. The highest level of conlamination found on t$e RES
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l-Technician cas 120 mrad /hr which was located on his left thumb.
This
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reading and tubsequent readines were uncorrected, open window, ion
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chamber readiogs taken a> proximately 1/8 to 1/2 of an inch from the
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surface of the skin of tte thumb.
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The RES Technician then showered.
The next survey indicated that the
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contamination had been removed from all areas except the hands.
The RES
Technician then washed his hands with soa) and water using a soft nail
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brush. After three washings the ion cham >er reading for the left thumb i
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was 90 mrad /hr. The licensee then had the RES Technician soak his hand
Na 24 for stable sodium. pparently assist in an ionic (xchange of the in a saline solution to a i
At approximately 6:10 p.m. on March 8, 1990,
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the ion chamber reading for the left thumb was 48 mrad /hr.
Further decontamination efforts were made using potassium permanganate i
and sodium bisulfite and additional soaking in a saline solution. At
34 mrad /hr. y 9:00 p.m. the ion chamber reading for the left thumb was approximatel
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Based on the minor decrease in contamination levels achieved
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the potential for chemical damage to the skin, during the last soakings, life of the nuclide (15 hours1.736111e-4 days <br />0.00417 hours <br />2.480159e-5 weeks <br />5.7075e-6 months <br />)$ icia and considering the half the licensee
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stopped further decontamination efforts and the RES Tec n was released from the site.
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l The RES Technician wore two rubbe(o! oves on his left hand and one ol right hand, which sit 11 had some levels of contamination.
The RES while offsite, given a bicassay bottle for collection of a urine sample Technician was i
j The next day, March 9 1990 the urinalysis was completed and a whole l
bodycountwasconducled, theresultsofthesetwoevaluationsindicated
to the licensee's personnel that the N4 24 had not been transferred to
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the systemic fluids of the body. At approximately 3:00 p.m. on March 9,
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1990, the ion chamber reading for the left thumb was 12 mrad /hr. The l
licensee's personnel then routinely monitored the RES Technician's thumb
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until the morninq of March 13, 1990. At that time, no contamination was l
detected on the
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l The licenree's immediate corrective actions for this incident included:
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Restricting the RES Technician from the controlled areas of the
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facility, j
l Upgradina the protective clothing requirements >rior to the next i
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test which was conducted on March 10 1990. Tse upgraded r
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regulrements for the workers included, coveralls and plastic aprons, i
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The RES Technician covering the job was required to wear coveralls,
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cotton boots with rubber shoe covers, rubber gloves with cotton i
liners, and surgeon oloves.
No personnel contaminations occurred i
duringthesecondinjection.
Providing the other RES Technicians involved in the testing
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)rocedure specific radiological training in precautions for the
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Sandling of high specific activity liquids.
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t Upgrading the skin decontamination procedure to include actions to
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be taken for personnel contaminations involving Na 24.
f 4.0 Dose Assessment The licensee's initial calculation indicated a total dose equivalent of
480 mrem to the skin of the left thumb of the worker.
This estimate was based on a worksheet contained in the licensee' preliminary s procedure I
Personnel Contamination incidenfs[igure 8.1 of ' Dose Assessment of for initial skin dose estimates PDP ll.
The preliminary estimate l
apparentlywasbasedonthecontamInationbeinganextendedsourcewhich remained on the skin for two hours. The licensee's use of the procedure i
resulted in significantly underestimating the potential dose equivalent to the worker. The licensee's personnel recognized the limitations of i
I the procedure and initiated action to better evaluate the dose to the
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I thumb.
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l A more detailed analysis and subsequent dose evaluation, using a dead
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skin layer density thickness of 40 al11tgrams per centimeter squared resulted in a dose equivalent of 24 to 27 ren to the skin of (mg/cm2
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the indhv,idual's thumb as compared to the NRC quarterly limit of 18.75 ren to the extremity (at a depth of 7 mg/cm2).
Based on * reference man' values from the Interriational Commission on ICRP 23) and the results of a Radiological Protection Publication 23 (hands, the licensee decided to
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physician's examination of the worker's I
evaluate the individual's dose through a dead skin layer density
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thickness of 64 mg/cm2.
Using this value resulted in a dose equivalent estimate of approximately 18 rem to the extremity, j
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However, the inspector noted that the physician's lette? documenting the
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basis for the licensee's decision to assign a dead skin layer of i
64 mg/cm2 addressed the skin on the palms of the hands and did not
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specifically address the area contaminated. Additionally, the supervisor who assisted in decontaminating the worker noted that chemical decontamination was appropriate because the contaminated area was fresh unbroken skin that appeared free of callus.
The licensee stated that
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they plan on consulting a dermatologist to better assess the density thickness for this assessment.
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The inspectors noted that the licensee exhausted efforts to free the contamination from the skin of the left thumb and eventually decided to i
allow the worker to leave the station contaminated. The inability to i
remove contamination after four hours of aggressive effort by trained
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individuals appears to indicate that this material may have become
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incorporated in the dead layer of skin. Therefore, it appears
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inappropriate to utilize a large density thickness value which would assume that the contamination was on the exterior surface of the skin.
Notwithstanding this effort to account for thickened skin on the hand, 10 CFR 20.401(aD requires that personnel exposure records be kept in r
accordance w9th the instructions contained on Form NRC 5.
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requires the licensee to report skin dose through a density thickness of
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not greater than 7 mg/cm2. An early calculation performed by the i
licensee using this value resulted in a dose equivalent of approximately
55 rem to the skin of the thumb. The licensee stated that for this
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exposure it was not appropriate to evaluate and report the dose i
equivalent through this density thickness.
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At the end of the inspection period the licensee's personnel were still i
refiningthemethodofdeterminingIhetotalactivityofNA24,whichwas i
L on the skin of the RES Technician. The final assessment of the extremity exposure to the individual remains unresolved. (50 333/9012-01)
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l 5.0 Conclusions l
I The licensee had evaluated the radiological hazard associated with injecting the Na 24 into the primary system and concluded that because of f
the slow rate of injection and the massive dilution, hazard to personnel the Na 24 did not
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represent a significant external radiation exposure or a significant contamination hazard in other portions of the plant.
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The procedure which controlled the overall flow testing was station
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approved procedure POT /SPT No. 34b, ' Tracer injection Test for feedwater
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Flow Calculation *, incident on March 8The work being conducted at the time of
Revision 0.
the contamination 1990 was controlled by rocedure
Revision 0 ' Pre >arationofNa24injectionSolution.
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NWi INSOL,NWT !NSOL is, a su) procedure of POT /SPT No. 34b. The only Procedure t
reference to radiological controls in procedure NWT INSOL was ' observe
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all radiological precautions and requirements *.
Step 15 of Procedure
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NWT INSOL Revision 0, states 'Using the capsule ce removal tool and tongsorlongtweezers remove the capsule cap and lace it in 4
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disposable container.', The RES Technician placed i e contaminated cap on
the capsule with his gloved hand and did not use any of the specified
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tools, tongs or tweezers.
The controlling and sub procedures for the flow testing delineated a)propriate steps to ensure injection system integrity and execution of
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tie test process. However, the procedures did not incorporate specific
i radiological controls. The procedures relied on existing radiation i
protection procedures to safely control the handling and disposal of the
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tracer, Na 24.
j The licensee's personnel did recognize the need to look for leakage in the immediate vicinity of the injection area due to possible leakage from l
In addition the licensee had hydro tested the i
components in the area.
flow injection system to ensure leak, tightness during the injection. The
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l procedures provided specific guidance to look for leaks in the area of
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I the injection. However, it provided no guidance as to what actions to f
take upon identification of a leak.
The radiation work permit providing
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I controls for the job also did not address actions upon identification of j
a leak.
The efforts to review the area for leaks appeared to be directed at ensuring an accurate flow test rather than attempting to identify a
radiological hazard.
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The inspector noted that the radiation work ermit was established and
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implemented by the RES Technician who provid d the radiological oversight
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of the Na 24 injection. The inspector noted that the RES Technician had
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with landling the high specific activity Na gnificant hazards associated no ex>erience or working knowledge of the si i
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24 solution.
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The RES Technician established a radiation work pemit that allowed thi Also
>ersonnel to enter the injection area with no grotect9ve e se did not recognize the significant contamina ion hazard tent 1.
However the licensee's procedures pemitted this individual to establish
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the radlation work pemil for this activity.
The inspector noted that this pemit was subsequently approved by a Chief RES Technician.
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The inspector noted that Technical Specification 6.11, Radiation Protection Program, states that procedures for personnel radiation
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protection shall be prepared and adhered to for all plant operations.
l These procedures shall be formulated to maintain radiation exposures
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received during operation and maintenance as far below limits specified i
in 10 CFR 20 as practicable. The procedures shall include planningInation l
preparation and include exposure allocation, radiation and contam t
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control tech,niques, and final debriefing.
l The inspector concluded that the followine items collectively represent i
an apparent violation of Technical Specification 6.11:
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The contractor worker, who did not properly dispose of the i
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contaminated capsule cap in accordance with procedure NWT.INSOL, j
failed to adhere to a procedure step designed to minimize contamination.
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i The licensee failed to establish adequate radiological precautions t
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for this activity in that the protective clothing requirements were
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not adequate considering the radiological hazard.
The RES Technician entered and worked in the injection area with only shoe
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covers and surgeon's gloves. The radiation work permit
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not require any protective clothing for this individual,(RWP) did in
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addition the RWP procedure (No. RPP 4) did not require supervisory i
l reviewofthisRWP.
It was nuted that a Chief RES Technician did i
sign off on the pemit but this review did not identify weaknesses t
in the RWP.
i The controlling procedures and radiation work permit did not provide
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any guidance as to how to deal with Na 24 leaks.
j The licensee's radiation work permit >rocedure allowed an individual l
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l with no experience in handling or wor (ing with high specific
activity Na 24 to prepare the radiation work pemit for this
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activity and actually provide the operetional radiological controls
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for the injection of high specific activity Na 24.
The contro111nfs for performing personnel cont!aination monitoringermit didf procedures and radiation work
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any requiremen
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at or near the work location.
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The controlling procedures and radiation work permit did not ensure
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a thorough discussion of the radiological hazards of working with high specific activity Na 24.
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As a~ result of the above, the RES Technician contaminated himself with high specific activity Na 24 (at a level of at least 120 millirads per t
hour), the RES Technician did not perfom a timely frisk of his person i
for contamination the RES Technician subsequently contaminated other
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portions of his pe,rson, and later the RES Technician contaminated a
frisking station which resulted in other non involved personnel becoming
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contaminated with Na 24.
l The failure of the licensee to prepare procedures which include adeounte radiation protection precautions and requirements and the failure of the t
licensee to adhere to the written procedure steps which provide for I
contamination control is an apparent violation of Technical Specification , 6.11. (50 333/90 12 02)
l The areplanning efforts failed to propega 24 in this form.ly instruct the RES Technician the Tazards associated with the use of This is evidenced by the followings j
The lack of protective clothing requirements for the RES Technician i
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providing job coverage and the inadequate protective clothing i
requirements for others in the contaminated area.
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The failure of the RES Technician to evaluate the need to perform a
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L beta radiation survey of the work area. According to the RES l
Technician, he was not aware that Na 24 was a beta radiation
emitting isotope.
l The failure of the licensee to caution the RES Technician against
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directly handling the capsule cap at all times because the cap and capsule would have substantial levels of contamination remaining on i
them, i
The failure to instruct the RES Technician as to the tenacious
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adherence of Na 24 to the skin and the difficulty in decontaminating l
the skin and the need to perform timely frisking to identify any
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apparent contamination of the skin.
t 10 CFR 19.12 requires, in part that all individuals workino in or frequenting any >ortion of the, restricted area shall be kept informed of
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radiation in suci portions of the restricted area and shall be instructed i
in precautions and procedures to minimize exposure.
l The licensee's failure to properly instruct the RES Technician in l
precautions and >rocedures to minimize his exposure is an apparent
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l violation of 10 CFR 19.12.
(50333/901203)
i Supervisory oversight during the planning and initial operation phase of this activity was evident. However, the oversight of this activity was
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ineffective to ensure that adequate radiological precautions were taken
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by the individuals involved in this task.
This was evidenced by the lack
of instructions to the RES Technician covering the job and the ineffective review of the RWP which did not identify the weaknesses in r
protective clothing requirements, t
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Based on these observations and considering the licensee's history material in the spent fuel pool (See NRC Inspection (Report No.i.e. the floating involving non routine radiological work activities 50 333/89 13? and the overexposure to an individual involved with incere diffic/87-07)) it appears that the(See NRC Inspection Repo instrumentat90n dry tube removal
$0-333 licensee continues to experience ulties controlling non routine work activities involving potentially significant radiological hazards.
6.0 Exit Meeting The inspectors met with licensee representatives fdenoted in Section 1)
at the conclusion of the inspection on March 15 [990.Theins summarizedthepurpose, scope,andfindingsofIheinspection.pectors
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