IR 05000334/1989021
| ML19332E825 | |
| Person / Time | |
|---|---|
| Site: | Beaver Valley |
| Issue date: | 11/16/1989 |
| From: | Oconnell P, Pasciak W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML19332E824 | List: |
| References | |
| 50-334-89-21-EC, NUDOCS 8912130028 | |
| Download: ML19332E825 (55) | |
Text
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r U.S. NUCLEAR REGULATORY COMMISSION
REGION I
Report Nos.
50-334/89-21 < Docket Nos.
50-334' , License Nos.
DPR-66' Category C " Licencee: Ouquesne Light Company , One Oxford Center-301 Grant Street L Pittsburgh, Pennsylvania 15279 L Facility Name: Beaver Valley Power Station, Unit 1 ~ Meeting At: NRC Region I, King of Prussia, Pennsylvania s Meeting Conducted: November 13, 1989 , Inspector: ?X & //-/ '/ 91 . P. O'Connell, Radiation Specialist date Approved by:, A/. A.df/5 h!/k!8f , W. Pasci~ak, Chief, Facilities Radiation / dito , ' Protection Section Meeting Summary: Enforcement Conference at NRC Region I, King of Prussia, Pennsylvania, on November 13, 1989, to discuss the findings of NRC Combined Inspection Report Nos. 50-334/89-21; 50-412/89-20. The topics discussed related l' to the unplanned exposure to an individual working on the secondary side of a steam-generator ~on September 28, 1989.
L The meeting was attended by NRC and licensee management and lasted for approximately two hours.
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p i ( r DETAILS 1.0 Particip_ ants-1.1 Duquesne Light Company , E. Cohen, Director, Radiological Operations (BV2)V1) Radiological Operations (B 0. G4rdwood, Director, lear Safety J.Kosmal, Mar,ager,Nuc. Manager, Radiological Control K. Grada
W. Lacey, General Manager, Nuclear Operations Services . J. Sieber, Vice President Nuclear Group R. Vento, Director, Radiological Engineering 1.2 NRC Personnel R. Bellamy, Chief, Facilities Radiological Safety and Safeguards Branch K. Christopher, Enforcement Specialist C. Cowgill, Chief, Reactor Projects Section 4B J. Greeves, Acting Deputy Director, Division of Radiation Safety and Safeguards P. O'Connell, Radiation Spe::ialist W. Pasciak, Chief, Facilities Radiological Protection Section P. Tam, Project Manager P. Wilson, Resident Inspector, Beaver Valley
2,0 Purpose The Enforcement Conference was held at the request of NRC Region I to ' discuss the circumstances relating to the unplanned exposure of an individual working on the secondary side of the B-2 steam generator on September 28, 1989. The discussions at this meeting focused on: the identified apparent violations, the root cause of the event, and licensee corrective actions to prevent recurrence.
3.0 Licensee Presentation The NRC began the conference by emphasizing their concerns regarding this unplanned exposure and the apparent similarity to previous occurrences at the Beaver Valley Power Station. The licensee began their presentation by emphasizing that they too were highly concerned regarding this matter and that they were committed to making tne necessary changes in order to preclude a similar incident from occurring in the future. The licensee presented the NRC with several handouts which are enclosed with this report.
The licensee stated that the findings noted on NRC Combined Inspection Report 50-334/89-21; 50-412/89-20 were essentially correct. The licensee stated that they had additional information which could address some of the findings.
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9 survey /89-20 noted that thewere appro NRC Combined Inspection Report 50-334/89-21; 50-412 dose rates indicated on a September 13, 1989 half the dose rates indicated on a survey which was completed after the unplanned exposure.- Tho licensee reviewed this finding and determined that the difference was due to the survey instrument being )ositioned differently for the two surveys. The licensee stated t1at the differences in the survey results would not have affected the radiological controls - for the work and therefore did not contribute to the unplanned exposure.
The licensee reviewed how the stay time, which is the amount of time an individual-could have their arm inside the steam generator, was determined, and how the exposure controls for the work on the secondary side of the steam generator were determined. The licensee stated that, in the past, hat l.
individuals rarely insert their arm fully into the steam generator and t L-based on how the work had been performed in the past, the exposure controls ' implemented were appropriate.
The licensee determined the root causes of this unplanned exposure to be: Poor judgement was exercised by the Radiological Controls Technician (RCT), in that, pocket dosimeters were not read at a frequency that . related to the exposure rate.
! "Stop Work Authority" was not exercised by the'RCT.
' The work crew did not respond to a request by the RCT to read their l dosimeters.
l The workers performing the task were not positively identified.
NRC Combined Inspection Report 50-334/89-21; 50-412/89-20 noted that a previous NRC-Inspection Report (50-334 identified a similar lack of controls during significant radiologic /88-03) tions. The licensee stated al opera that, although the inspection report addressed both primary and secondary side steam generator work, the emphasis of that report finding was on i primary side steam generator work. The licensee stated that, subsequent to primary side steam generator work. ged their radiological controls for the that inspection finding, they chan I l The licensee discussed their dose assessment to the individual involved.
The licensee assigned a whole body dose of 2076 mrem for the calendar quarter to the individual, which is within the NRC regulatory criteria of 3 rem per calendar quarter.
The licensee stated that the survey performed for the control of the work on the steam generator, including the actual dose rate measurements and the established exposure control limits, were appropriate. The licensee stated that the unplanned exposure was a result of the established radiological controls not being implemented.
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i l ~ The licensee stated that in their o l constitute a " substantial potential" pinion, this incident did not for an individual to receive an exposure in excess of 10 CFR 20 limits.
The licensee also reviewed initiatives which they have undertaken in order to reduce personnel exposures at their facility.
4.0 Concluding Statements NRC Region I management acknowledged that the actions presented appeared to be responsive to the NRC's concerns. NRC Region I management stated that the licensee would be informed of the need for and the nature of appropriate enforcement action relative to this incident at a later time, . L
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i-DUQUESNE' LIGHT COMPANY 4.i INFORMATIONAL HANDOUT for
i NUCLEAR REGULATORY COMMISSION l ENFORCEMENT CONFERENCE i' at KING OF PRUSSIA, PA
on , ! November 13,-1989 ! l l I l
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ENFORCEMENT CONFERENCE A*JENDA-November 13, 1989
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.?]..slaTJ;. ^: ? J a. f I *. R- ;;ni!!@g ' - _ Subject: NRC Combined Inspection Report 50-334/89-21; 50/412/89-20 1.
Introductions NRC/DLC ' 2.- Synopsis of Infractions Described NRC
in NRC Combined Inspection Report 50/334/89-21; 50/412/89-20 3.
Questions and Comments Related to NRC/DLC Infractions as Described, Opening Comments p 4.
Workscope, Description, Chronology of Events [ Secondary Side Survey Adequacy DLC . 5.
Development of Stay Times DLC 6.
Event / Causal Factor Analyses DLC Whole Body isose DLC
- 7.- Summary and Conclusions '10CFR2 Appendix C
Broader Implications
l-Substantial Potential
8.
Open Discussion NRC/DLC 9.
Closing Remarks DLC 10. Initiatives to Minimize Exposure (Optional) DLC l $E@@ M 8 8 4,2 & E M$$$
! DUQUESNE LIGHT ATTENDEES J.
D. Sieber - Vice President, Nuclear Group W.
S.
Lacey - General Manager, Nuclear Operations Services K.
D. Grada - Manager, Nuclear Safety J. A.
Kosmal - Manager, Radiological Control R. M.Vento - Director, Radiological Engineering . D. O. Girdwood - Director, Radiological Operations (BV1) E.
D. Cohen - Director, Radiological Operations (BV2)
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WORK SCOPE . DESCRIPTION l and " CHROX0 LOGY OF , EVENTS 1: I L
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' . ' . > STEAM GENERATOR SECONDARY-SIDE , FOREIGN OBJECT SEARCH AND RETRIEVAL i ' (FOSAR) , OBJECTIVR: 'Ihe objective of POSAR is the inspection, identification, and retrieval of loose foreisn objects from the secondary-side of a steam generator.
j i ! WORK S00PE: To acocaplish FOSAR at the Beaver Valley Power Station, an extensive ] remote video inspection was performed of the following areas in the j secondary-side of the steam generator: tube sheet rows, wrapper, annulus and annulus drains, blowdown lanes, beneath the blowdown piping, and the ] feed ring. Additionally, the area around the seventh support plate was i inspected and two tube lane blocking devices were periaanently removed from two steam generators at Unit 1.
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BACKGROUND: During previous repairs perfonned on Unit 1 feedwater regulation valves, ' it was found that parts were missing and vere believed to have ettered , the feedwater system. Because a foreign object was known to have caused a tube leak in June of 1989 at the Besver Valley Power Station Unit 2, the location, identification, and retrieval of any foreign object in the secondary-side of a steam generator is highly desirable. As FOSAR, in conjunction with eddy current examinations, has proven since 1982 to be an effective method to perform secondary-side foreign object location, l identification, and removal, the use of POSAR was again employed during the seventh refueling and maintenance outage at Unit I which began in September 1989.
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? i CHRONOLOGY ' , Unit 17R FOSAR Event l ! , . . l Sept. 12 RWP 16297 for S/G secondary-side FOSAR work was generated and approved at 0950.
j Sept.13
Pre-work briefing conducted. Insulation and handhole flanges removed from 1B S/G.
Survey of tube lanes and handhole performed.
TID " tree" test irradiation performed to determine extremity exposure controls.
l . Sept. 14 Pre-work briefing conducted. Setup of video equipment initiated. General area exposure , rate survey performed.
Instituted extremity exposure control level of 2R on pocket dosimeter. Continued control , level through Sept.19 until TLD " tree" results were obtamed and evaluated.
~ Sept. 15 . Pre-work briefing conducted. Video inspection activities continued. General area exposure rate survey performed.
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Sept.16
Pre-work briefing conducted. Crew entered
cubicle to obtain temperature readines in i handhole as the FOSAR camera equipinent would not operate reliably at temperatures t greater than 100 degrees F.
' her temperatures were anticipated as S/G , l ? ary-side chemical decontamination was , m progress. Subsequently, FOSAR work was suspended until completion of decontamination.
General area exposure rate survey performed.
Sept.17 -- 18 , i FOSAR work suspended.
Sept.19 ' TIE " tree" evaluation completed. Results ~ indicated that' limiting extremity exposure to 2R by <>ocket dosimeter was no longer ' warranted. Reinstituted Radiological Control manual extremity exposure administrative control level of 4R by pocket dosimeter.
! Evaluation also indicated that ring TLDs were no longer required for FOSAR work.
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' . , ' S/G HANDHOLE SURVEY DATA ' Unit 1 - S/G 1B - Handhole B2 i TLD " TREE" RESULTS FROM TEST IRRADIATION ON SEPT.13 rem /hr
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. TLD " TREE" RESULTS FROM TEST l IRRADIATION ON SEPT.13
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- - - _ _ - - . . - - - - . . . . CHRONOLOGY ' Unit 17R FOSAR Event Sept. 20 - 21 Pre-work briea conducted. FOSAR inspection work restarted.
neral area and handhole verification survey performed as primary-side decontamination was essentially complete.
, Verification survey indicated that relative
exposure rate gradients had not changed significantly from the Sept.13 survey.
Sept.21 - 22 j Pre-work briefm' g conducted. FOSAR inspection work continued. Results of video inspection l indicated 7 identifiable aarts on tube sheet.
Setup for parts retrieval initiated. General area exposure rate survey performed.
Sept. 23 Pre-work briefing conducted. FOSAR retrieval ~ activites continued. Crew moved a few parts to a position of retrievability by use of a ' remo;ely operated water lance. General area l exposure rate survey performed.
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CHRONOLOGY Unit 17R FOSAR Event Sept.24 Pre-work briefing conducted. FOSAR retrieval activities continued. First loose part extracted.
General area exposure rate survey performed.
. ! Sept.25 - 27 l ' FOSAR work suspended and equipment removed ! while B2 handhole machinina work was performed.
Pre-work briefing conducted for machinina work.
' General area exposure rate survey performed.
. Sept. 28 Pre-work briefm' g conducted. FOSAR retrieval activities restarted. General area exposure rate survey performed. After removal of a piece of flexitallic gasket, one worker's extremity pocket dosimeter was noted to be offscale.
~ FOSAR activities stopped. Worker's dosimetry sent for processing and evaluation. Director of Radiological Opera dons notified. Investigation initiated.
Sept.29 NRC notified of incident prior to exit meeting for Inspection 50-334/89-21; 50-412/89-20.
! Additional exposure rate surveys performed in handhole.
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PORTABLE SURVEY INSTRUMENT RESULTS FOR SEPT.13 and 29 , R/hr 20 20-se "* Reference Distance
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{\\\\\\] 1.2 {\\\\\\] Handhole Flange "1 2 -' 1-1/s" thk Fandhala 9/13 9/29 Into Tube 6" dia l l
._ _ _ _ - _ - _ - - _ - _ - - - - -. _ . _ - . S/G HANDHOLE SURVEY DATA ' ' Unit 1 - S/G 1B - Handhole B2 . TELETECTOR SURVEYS (2") . "' * Reference Distance .5 (in es) - L - 5.0 -
H - 3.0 - , " i
- '
J /J 9/13
- ,
N N 3 R/hr . Teletector Scales Low High 2 mR/hr 50 R/hr
hr 1000 R/hr
hr
i - . . , .-
S/G HANDHOLE SURVEY DATA ' Unit 1 - S/G 1B - Handhole B2 \\ TELETECTOR vs. RO-2A SURVEY (Plane of Handhole) . .aeoo w _:as - - 6.5 - y m, , (inch ) . . - 5.0 ' - - 4.5 -
/ - 4.0 - / 2R/hr- - 3.5 /
f,, - /
o.j5 j' 112" RO-2A a ' O - - 1.5 . - -2.0 . i RO-2A Scales Teletector Scales 50 mR/hr Low High 500 2 2 mR/hr 50 R hr
hr 1000 /hr
/hr . - . -
. . - . . . .
S/G HANDHOLE SURVEY DATA ' Unit 1 ~ S/G 1B - Handhole BS . , DETECTOR POSITIONING DIFFERENCES ' .pwrewM . - 6.5 - '. l $" " m e h m hfe " M )**** ' ( - 5.0 i - lN.i [ ' , , - 3.5 - 8 R/hr - -30 G . ' 3 R/hr 2- ~ 2 R/hr ~ --0.5 - - - 1.0 - 1.2 R/hr _ _1,5 . - -2.0 ~ 9/13 9/29 . DIFFERENCES IN SURVEY RESULTS ARE EXPLAINABLE and THEREFORE l ... NOT RELATED TO EVENT ' ~... -.. . ... ... .. .. . .
, . l . . , .
+ I i l '
l ] I
l , I . WHOLE BODY . Y I
i vs.
, l l ' EXTREMITY l STAY-TIME - '
- - - -.... ---__- .: ., . . . ADMINISTRATIVE EXPOSURE CONTROLS BVPS Units 1 and 2
h
Assumes completed Form NRC-4 l --- Record Dose: j Whole-body: . 3000 mrem /qtr 5000 Irirem/yr l 2700 mrem /qtr # 4700 mrem /yr # l Extremity: ) l 15000 mrsm/qtr ! 14000 mrem /qtr # ~~ - f Plant Manager authorization to exceed value shown _. _ _ , /dert Status (lower threshold): l ' Whole-body: 1000 mrem /qtr 3000 mrom/yr - Extremity: 5000 mrem /qtr
l
- -.,... -, _.. ~. _ _ _ _ _. _ _ _ _ _. _. _ _ _., _ _., _ _ _ _ _.. _, _.,, _, _ _., _ _.., _,, _ _. .
_ _ _ _ _ _. _ _. _ _ _ _. _ _ _ , . . . . ' ADMINISTRATIVE EXPOSURE CONTROLS ' BVPS Units 1 and 2 Assumes completed Form NRC-4
-__ I Pocket Dosimeter (routine): ' Whole-body: . . 800 mR i L Extremity: L 4000 mR l
--- . ! Example: ' -
Worker's whole-body quarter dose to date l .. 1500 mrem ' Whole-body quarter administrative control level - .. 2700 mrem l Worker's whole-body quarter dose remainina j .. 1200 mrem ( 2700 mrem - 1500 mrem 7
Pocket dosimeter control level: ! Safety factor of 2 or greater applied: ! ( 1200 mrem / 2 ) = 600 mR , WORKER WOULD BE LIMITED TO: 600 mR on whole-body pocket dosimeter [
I . _ -.,. _ ~ _.... _ -.... _.. _., _..., -. _ _. - _... _,, _ _ _ _,,, _ _ ______,______.--..___,,,._....._._-r-.__
> . . . . . . 'S/G HANDHOLE SURVEY DATA.
' . -- - - - Unit 1 - S/G 1B'- Handhole B2' ' - . . E FN E M , . > , L-m" 6.6 /* FlaBSe Faos ) . 6.0 ) - 5.5 -
5.0 i . '
' /
- 4.5 ' . . , / p ' 4.0 NOR. MAL WORK h . . s.5 l merHoe warn usut> . WAS RESutRED To 3.0 ' . ! em na How.HAwo ' E%Po supe WTRouro 2.5 . . . Tb \\O R/HR UM ) U 2.0 F ,r . - 1.5 VPere NtM our . 1.0
- or Hea.x ~taf 0.5
3 Mft,/Mty -
- 0'
t 2. we,/wm , . I e I--,-...w,...,m,.r__,,_,. ,,,,,y,,,%%...r, .,. ,,9.,,,. n.,,. ,,,..,.-,,,w..__,_,,,.._,._...,,m , _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
' . . . .
EXTERNAL EXPOSURE CONTROLS Unit 17R FOSAR Event GENERAL CASE Administrative Pocket Dosimeter Control Levels: 800 mR whole-body 4000 mR extremity ___ Whole-Body Control Level Stay-Time: ~ Based on exposure rate at plane of handhole , .. 1200 mR/hr (20 mR/ min) ' and
Based on pocket dosimeter control value of i
.. 800 mR ! ! ( 800 mR / 20 mR/ min ) = 40 minutes I ! . ___ l Extremity Control Level Stay-Time: ! Based on exposure rate inside handhole .. 10 R/hr (167 mR/ min) and . Based on pocket dosimeter control value of .. 4000 mR ( 4000 mR /167 mR/ min ) = ~24 minutes Therefore, extremity control level is most limiting and stay-time to be used is .. 24 minutes j ..., - -.....,,., _,... -.. _ _.. _. _ _.. _ _ _... _, __.., _ _ _ __._,.____ _ ________ _ _ _ _ _ _____________ ___ . _ _,, _ _ _
. . . .
.- E EXTERNAL EXPOSURE CONTROLS Unit 17R FOSAR Event SPECIFIC CASE , Administrative Pocket Dosimeter Control Imvels: 490 mR whole-body 3610 mR extremity ' ___ ' Whole-Body Control Level Stay-Time: Based on exposure rate at plane of handhole j, .. 1200 mR/hr (20 mR/ min) ' - and ' Based on pocket dosimeter control value of .. 490 mR ( 800 - 310 ) > ' ( 490 mR / 20 mR/ min ) = 24.5 minutes
___ Extremity Control Imvel Stay-Time:
Based on exposure rate inside handhole - l .. 10 R/hr (167 mR/ min) l ed . Based on pocket dosimeter control value of l .. 3610 mR ( 4000 - 390 ) l ( 3S10 mR /167 mR/ min ) = 21.6 minutes ' ___ ' Therefore, extremity control level was most - limiting and stay-tune used was .. 22 minutes.
CONTROLS REASONABLE UNDER CIRCUMSTANCES - - -. -. - . - - . - - - - - - - - - - - -.
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- . .,- S/G ~HANDHOLE SURVEY DATA . ' . . . ' - - . .Un S/G 1B'- Handho.le B2' ' - ' b - < m 6.5 . - F.o.
- Froma( ) ' ' . 6.0 - 5.5 S 4R/HR, _ ry - 90mR/utw 5.0 - . S. 64 R/HR_ et - 4.5 - - - 94 MR/Msw - 4.0 - 3.5
- ,
- , 3.0 - E94 R/ Wit +X - 3.5 66mR/HiN - - 3.0 -
' ! '3,5RjkR g - 1.5 . ssmR/ sty L ' . - 1.0 - - ! L e - 0.5 > l 9/so/d9 - 0.0 ED1 OM TM4AWT6M ARM DtSTANces APeRox,
- -... -... ... .. . . P'nD--- -. mm _,, _ __
.' . .. i . . S G'HANDHOLE SURVEY DATA ' ' ~ Uni G 1B' - Handhole B2' '
388NWW388938B3 L / . x-6.5 '- From Taos - \\ i.7 R HR ( ) 6.0 195 MR/MnW -
.. G As R/HR,g I b "" /"'" 5.0 - - - 4.5 - 4.0- -
- 3.5 - 3.0 i 10/T/89 - .
t i. c s oN PHAuftem Ntm
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. - - . - - - - - - - - - - - -. - .- w . . , , S/G'.HANDHOLE SURVEY DATA - Unit 1 - S/C 1B'- Handhole B2 . I TLD. oN PHAuToM ~ 5.625 RA4R ARM-FULLY tN S ERTED i 194 MR/Mt , 9/29 /#9 HANb ON TUBE SHEET
. . ' \\ \\ TVSE
f #; 6 '. 4 R/HR - N , i 110 MR/ MIN
It.9 R/uR @ 4 8 9A4R ~
- 19 BMR/ Mig
, 6.
F ' too MR/utt - l y .. , no/s/sq - NAMD WEAR TuEiE S . - @ VALOE USED FOR WHoLE - 800Y DOSE As s E SS MENT . .. .... .. .. . . ... .. . . -
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' " -WHOLE. BODY DOSE ' ASSESSMENT ' - -
Unit 17R FOSAR Event
Worst-case: estimat'e used: . .
- Time upper arm (above elbow) was fully inserted into S/G handhole
.. 13 minutes . .. I L
- Dose rate to upper arm determined from i
mannequin arm test in S/G handhole l .. 108 mrem / min l Additional dose assigned from event: ( 13 x 108 ) = 1404 mrem whole body - --- i
- Record dose from whole body TLD worn l
Sept. 2 -through Sept. 28 - . .. 552 mrem . Record dose for period (after assessment): L ( 552 + 1404 ) = 1956 mrem whole body l l l t ! .. _. - . _ - _. _ .. _. _ _ _. _, _,... _. _. _... _ _. _ _ _. _ _ _ _ _
. - . -, < . . .. . . WHOLE BODY DOSE ASSESSMENT . Unit 17R FOSAR Event
- Calendar quarter record dose from TLD's for period July 1 through Sept.1
... 120 mrem . Calendar quarter dose (after assessment): ( 120 + 1956 ) = 2076. mrem whole body L L ___ L L
- Calendar year record dose from TLD's for period Jan.1 through Sept.1
.. 562 mrem Calendar year dose (after assessment): - L ( 562 + 1956 ) = 2518 mrem whole body
._.__.._.__.._.._._..-._.,,.__,_....____._.__ _..._____.._..___ _ __ ___ _ __ -- . . _ _ _ -i
,.;,a.
- . -
i . IMMEDIATE . . i I and
LOXG TERM , -
$ CORRECTIVE , . ACTIONS , .
. - -. - _ - -. -. - _ _ - - - - - _ _ " .. . . , I.
IMMEDIATE CORRECTIVE ACTIONS - ' Unit 17R FOSAR. Event - l l l
- Immediately stopped work and removed FOSAR crew from controlled area
- All FOSAR work terminated Sept. 29 at 0800
- Critique held Sept. 29 at 0815 l
l
- Special outage management meeting held l
Sept. 29 at :.300 by General Manager, L Nuclear Operations to discuss / emphasize L importance of supporting and obeying requests made by RadCon personnel- -* Survey performed in area directly above tube sheet where individual's hand was located
- S/G secondary-side mockup used to
. , develop additional survey techniques L
- Survey performed in area immediately L
inside handhole where individual's ! upper arm would have been located if arm was fully inserted into S/G l l l _,,......, -. -.. - - -,. -.. -. ~.. -. - - - - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - - _
' .. . . . . . IMMEDIATE. CORRECTIVE ACTIONS l - . - - Unit 17R FOSAR Event l L Additional verification survey performed
to verify stability of exposure rates used by RadTech for stay-times I RWP procedure revised to incorporate
a new form specifically for tracking ' extremity exposures for S/G handhole and other similar work i
- TLD " tree" results used to establish dose gradients.inside S/G handhole
- L .FOSAR contractor provided a letter L
- L acknowledging acceptance of additional L controls discussed and established - l at critique , Director, Radiological Operations issued
letter to. RadCon outage management emphasizing "STOP-WORK" authority L Disciplinary action taken for contractor '
RadTech involved in event I - *.., -.. - _. . _., _ _ _ _ _ _ _ _, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _,, _ _ _ _ _ _ _ _ _ _, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ,, _ _ _ , _
. .
- ..
, . D .. LONG-TERM CORRECTIVE ACTIONS . u Unit 17R FOSAR Event
-term corrective actions specific Long/G secondary-side FOSAR work: to-S ,
- Develop and implement a maintenance
and inspection control work package , l: for S/G secondary-side work.
' L
- Require all FOSAR work to be performed through a 2" openiHg, unless specific RadCon and management authorization
' to work through a 6" opening is obtained.
Long-term-mitigation actions that are not task specific: . L
- Institute an ad hoc assessment group to review event and recommend actions for long-term mitigation of root causes identified by HPES.
... complete l l -.. -,...... - _...,,.. _...,.... -.... - _ - -. - . .-
- .. . . .- . .
- LONG-TERM MITIGATION ACTIONS
'
Unit 17R FOSAR Event ' . Long-term mitigation actions recommended by ad hoc assessment group: Note: " Critical task", as used below, pertains - to work where the potential is high for a worker to receive a relatively high dose in a short period of time.
- Assign RadCon " Quality Assessors" to i
provide management oversight of critical tasks.
- Require a DRD reading and recording frequency be established prior to performing any critical task.
- Develop and implement a critical task exposure authorization program for whole-body and extremity exposure.
l l
- Continue evaluation of new equipment appropriate to monitoring personnel during performance of entical tasks.
l l ! -. - -
. V" " SUBSTANTIAL POTENTIAL" .
e DATA BASE - NUREG 0940 SIGNIFICANT ENFORCEMENT ACTIONS (1986 -+) i - LIS SEARCH ON ALL NRC VIOLATIONS ISSUED INVOLVING RADIOLOGICAL EXPOSURES (1976 -+) - 27 ENFORCEMENT CONFERENCES - 72 NOTICES OF VIOLATIONS , L e RESULTS L - NO DEFINITION OR CRITERIA FOR "SIGNIFICANT POTENTIAL" - DISCRETION APPLIED - NO ACTUAL OVEREXPOSURES INVOLVING SECONDARY SIDE-WORK ON THE STEAM GENERATORS - TWO VIOLATIONS RELATED TO SECONDARY S/G WORK , - - NO HP COVERAGE DURING SECONDARY SIDE MAINTENANCE . - INADEOUATE MONITORING DURING SLUDGE . LANCING l l z.= -. -. .. -. - - . -. . - - - - - -.. -
_.
.- _.. - _ _ _. ___ _.
_ _ _.._.. _ _ _ _ , g:n :,:
.o-i , o: ACTUAL OVEREXPOSURES
. . t COUPLED WITH' INADEQUATE' SURVEYS - AND/OR. CONTROLS ' ~ l , o PRIMARY. AREAS OF OVEREXPOSURES: ' . , INCORE INSTRUMENTATION OR TRAVERSING - - s INCORE prose . r
< PRIMARY SIDE OF STEAM GENERATORS - - p ' - - HANDLING IRRADIATED COMPONENTS, INCORE EQUIPMENT, SPENT FUEL
REACTOR CAVITY, SPENT FUEL PIT, - DRY WELL- . g HOT PARTICLES - . h SPENT RESIN . - ! l -- UNDER REACTOR VESSEL OR STEAM GENERATORS UNSPECIFIED HIGH RADIATION AREA ENTRY -
w/0 HP COVERAGE l l l . -4*+ew-wr cew.w.v,w.
-wen #we m w m . _._.m,_____.
_,.___ ___. _. _ _ _ _ m.m .-- ._--..e.,,- ,*
. _ . . - - - - -. _ -- - _ _ _-- - - _ - - _
._ . O'
' x.. J . l ' . j Exposure Limits - REM Safety Limits - Pressure PSIG t \\ , i 18.75 2735 i .
- Regulatory Limit - Regulatory Umit ! . l
- ^ - Site Admin Limit - , ,9..%
.t . - I2%ALJA:: l .d l f& * " Eqq:j --- h67, 2385 Rx Protection I l
- Mf9.5 g MMB%
r.Ms@t,W - 50% b ' c - Actuanon - s W, = W =' l W.: 2"', - -- "
, .wn -
. . Y b h: , $h?.! ?lYs .f' ?: e #= w% 2310iP b @ Control System '9 .. h==#+e*+ - Actumuon i
! t 2250 ! [ CONTROLSYSTEM BAND-2235 \\ JOB DOSE CONTROL BAND
'f t i ? l i ~1 ~ - Substantial Potential for exceeding regulatory limit ! aw:31 - Moderate Potential for exceeding regulatory limit - Minor Potential for exceeding regulatory limit { - Controls Satisfactory
, P P i .. . - _ _., . . ,_.- . ...: -
- - -- - - - - g ' -@ _. ^ .- L, CONCLUSIONS e.
.. . ,
. j.
! ! ' ;
o ABSENCE OF INDUSTRY-EXPERIENCE INVOLVING OVEREXPOSURES DURING STEAM - GENERATOR SECONDARY -SIDE MAINTENANCE SUGGESTS ~A LOWER POTENTIAL FOR ! EXCEEDING REGULATORY LIMITS IN THIS AREA COMPARED TO OTHER HIGH.
i RADIATION AREAS DUE TO LIMITED ACCESSIBILITY i i ! o BV-1 EVENT HAD " MODERATE POTENTIAL" , t ! ! l - 30% MARGIN TO SITE ADMINISTRATIVE LIMIT ON EXTREMITY DOSE
i ' I - 46% MARGIN TO REGULATORY LIMIT ON EXTREMITY DOSE ' i CONTROLS ESTABLISHED FOR LIMITING JOB DOSE WERE NOT COMPLIED WITH i o ! ! l O SITE ADMINISTRATIVE LIMITS, INTENDED.TO MEET REGULATORY LIMITS, WERE l NOT EXCEEDED ! '
i ! [ t . . . ~ . . . . . ..
- _- -_.
.... - - -.- -- - -- c -,-. ra ;,....* lP ENFORCEMENT CONFERENCE. AGENDA ' November 13, 1989 , , - ,, ' - . _.; . _- . , _.__ ;: - q - ' - ., ~ Subject: NRC Combined Inspection Report 50-334/89-21; 50/412/89-20 l ~.s, y . ., - .+. g a.
. _ '_.
,, . .. y - , l' i Initiatives to Minimize Exposure (Optional) DLC l
- / S/G Platform Installation and Modifications'
I i .S/G Mockup for Secondary-side FOSAR work'
l [ pH/ Lithium Control Program Modifications
Feedwater Regulation Valve Modifications
! , CRDM Shroud Fan Bracket Modifications I
., Disc Pressurization System Modifications
' Participation in WOG Subgroup on Full RCS Decontamination
l i Chemical Decontaminaiton of Unit 1 S/G's . ! Cobalt Reduction Program
i u Large-Bore Snubber Reduction . P
L Small-Bore Snubber Optimization i
RTD Bypass Piping Elimination
] j S/G Manway Bolt-to-Stud Conversion
S/G Tube Sheet Access Modification I
Increased Steam Generator Blowdown Capacity
In-house Task Force on Boration Effects on CRUD Deposition
During Shutdown l i }}