IR 05000440/1989020
| ML20245L188 | |
| Person / Time | |
|---|---|
| Site: | Perry  |
| Issue date: | 06/26/1989 |
| From: | Schumacher M NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20245L111 | List: |
| References | |
| 50-440-89-20-EC, NUDOCS 8907050398 | |
| Download: ML20245L188 (4) | |
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U.S. NUCLEAR REGULATORY' COMMISSION
REGION III
Report No. 50-440/89020(DRSS)
Docket No. 50-440 License No. NPF-58 Licensee:
Cleveland Electric Illuminating Company Post Office Box 5000 Cleveland, OH 44101 Facility Name: Perry Nuclear Power Plant, Unit 1 Meeting Location: NRC Region III Office, Glen Ellyn, Illinois
i Meeting Conducted: June 7, 1989 Type of Meeting: Enforcement Conference h. (%8vl@
d 6/ 6/ff Approved By:
M. C. Schumacher, Chief l
Radiological Controls and Date Chemistry Section Meeting Summary Meeting on June 7,1989 (Report No. 50-440/89020(DRSS))
Enforcement conference to discuss a possible substantial potential for an overexposure, apparent violations associated with the matter, the licensee's perspective and corrective actions, and applicability of the NRC enforcement policy to these problems. Based on a review of information presented by the
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licensee and of the NRC Enforcement Policy, the NRC Region III staff has I
decided that a substantial potential for an overexposure did not exist and further escalated enforcement actions were not warranted.
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8907050398 890628 PDR ADOCK 05000440 p
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DETAILS l
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Meeting Attendees
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l Cleveland Electric Illuminating (CEI)
R. R. Bowers, Corporate Health Physicist G. R. Dunn, Lead Engineer, Licensing and Compliance Section, Perry Plant Technical Department (PPTD)
A. Kaplan, Vice President, Nuclear Group S. F. Kensicki, Director, PPTD L. L. VanDerHorst, Plant Health Physicist Nuclear Regulatory Commission T. G. Colburn, Senior Project Manager, Project Directorate III-3, Office of Nuclear Reactor Regulaticn L. R. Greger, Chief, Reactor Programs Branch, Region III l
M. A. Kunowski, Radiation Specialist, Region III D. E. Miller, Senior Radiation Specialist, Region III C. J. Paperiello, Deputy Regional Administrator, Region III M. A. Ring, Chief, Rea: tor Projects Section 3B, Region III i
M. C. Schumacher, Chief, Radiological Controls and Chemistry Section,
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Region III B. W. Stapleton, Enforcement Specialist, Region III 2.
General The enforcement conference wh: held to discuss the potential for an overexposure identified in NRC Inspection Report No. 50-440/89016(DRSS).
Also discussed were the apparent violations associated with the event, and applicability of the enforcement policy to the problems.
The NRC Region III staff summarized the inspection findings, apparent violations, and other regulatory concerns. The Deputy Regional Administrator emphasized that this event was the first serious breakdown in radiological controls at Perry, which is in its first refueling outage.
Licensee senior management officials indicated that they appreciated the seriousness of the matter, but contended that it was an isolated incident during an outage which otherwise demonstrated extensive planning and preparation and overall good radiological controls. The licensee then presented a description of the outage health physics program, the event itself, an explanation of the dose calculations and their assessment of the likelihood of a substantial potential for an overexposure during the event, and the causes, lessons-learned, and corrective actions associated with the event. The licensee's description of the event and its causes did not differ significantly from that provided in the aforementioned
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inspection report. The allegation findings and the apparent violations were not contested by the licensee. Additional information on the dose calculations, corrective actions, and lessons-learned provided by licensee representatives during this meeting is summarized below.
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An entry was made into the pit on March 21, 1989, before the jet shielding was removed, to remove insulation from the pipe.
Exposure time of the workers was minimum.
If the worker had completed the job of preparing the pipe welds
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after unpinning the snubbers and repinning the snubbers after the inservice inspection, he might have received between 1500 and 2700 mrcm.
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Error analysis of the dose reconstruction indicated a reasonable j
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dose range for the worker of approximately 350 to 1450 mrem.
The licensee attributed some blame for the incident to the workers,
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in that they should have been aware that the survey map associated with the RWP at the time of entry did not include the pit.
The licensee asserted that because of proper training, the workers
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conscientiously monitored their pocket dosimeters, thereby causing them to notify HP personnel of unexpected doses.
A directive was issued to all HP personnel regarding proper survey
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techniques and RWP methodology, including "stop-work" authority and notification of HP upper management when radiological conditions have unexpectedly changed.
Perry procedures on survey techniques, RWPs, work orders, Radiological
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Occurrence Reports, and Condition Reports will be revised to reflect lessons-learned from this event.
Specific training will be provided to all HP personnel upon completion
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of the procedure changes.
The licensee's Radiation Protection Manager (RPM) stated that after
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discussing the dose evaluation with the worker, the worker expressed reservations about the ability of the station's health physics group, the corporate health physicist, and the Perry " Call for Quality" group to objectively review his exposure.
The RPM stated that after hearing the worker's reservations he told the worker that he could express his concerns to the NRC.
Copies of the dose evaluation have not been given to the worker, on
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direction of the licensee's legal department; however, the report of exposure, required by 10 CFR 20.409, has been sent to the worker.
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NRC representatives commented that minimal blame should be attributed to the workers, stating that it'is expected that radiation protection technicians be more familiar with plant layout and validity of surveys than contract workers such as pipefitters.
In addition, NRC representatives asserted that at least for the second entry into the pit, the worker monitored hi.s pocket dosimeter because of apprehension not because of licensee training.
3.
NRC Review At the end of the licensee's presentation at the Enforcement Conference, the NRC staff commented that when RWPs are written for large areas, such as the drywell, the radiation protection staff must be diligent in conducting job-specific surveys, and that radiation protection management must encourage a sense of curiosity in technicians covering jobs. The Deputy Regior.al Administrator acknowledged the licensee's presentation and stated that the licensee would be informed of the decision about escalated enforcement at a later date.
As a result of. subsequent discussion among the NRC staff considering the information presented at the Enforcement Conference and the intent of the
" substantial potential for an overexposure" example in Supplement IV of the Enforcement Policy, the NRC decided that a substantial potential for an overexposure did not exist in this matter.
4.
Notice of Violation Four apparent violations of NRC requirements were identified during the inspection. These apparent violations were enumerated and described in Inspection Report No. 50-440/89016, but a Notice of Violation had not been issued when that report was issued pendiag NRC review of information presented at the Enforcement Conference by the licensee. As stated above in Section 2, at the Enforcement Conference the licensee did not contest the apparent violations or provide information that would cause the NRC to reconsider its findings; therefore, the Notice of Violation is being issued with this report.
The violation of 10 CFR 20.401(b), the failure to maintain a record of the survey that identified a hotspot reading 2.5 R/ hour (No. 440/8 d 16-02), was an isolated Severity Level V violation which was corrected betbre the end of the inspection. As allowed by the NRC Enforcement Policy 10 CFR 2, Appendix C, Section V.A., this violation will not be included in the Notice of Violation and a formal response from the licensee is not required.
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JUN 0 51989
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Docket No. 50-440 EA 89-112 The Cleveland Electric Illuminating Company ATTN: Mr. Alvin Kaplan Vice President Nuclear Group 10 Center Road Perry, OH 44081 Gentlemen:
This refers to the special special safety inspection conducted by Messrs. M. A. Kunowski and R. J. Caniano of this office from May 2 through June 2, 1989, of activities at Perry Nuclear Plant, Unit 1, authorized by NRC Facility Operating 1.icense No. NPF-58 and to the discussion of our findings with Mr. S. F. Kensicki and members of your staff at the conclusion of the inspection, and to the telephone discussion with Mr. G. Dunn and others of your staff on June 5, 1989.
The enclosed copy of our inspection report identifies areas examined during
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l the. inspection. Within these areas, the inspection consisted of a selective examination of procedures and representative records, observations, and interviews with personnel.
l During this inspection, certain of your activities appeared to be in violation l
of NRC requirements. We are releasing this report at this time for your I
information. Following the Enforcement Conference which has been scheduled l
for June 7, 1989, in the Region III Office, you will be notified by separate correspondence of our decision regarding enforcement actions based on the findings of this inspection. No written response is required until you are notified of the proposed enforcement actions.
In accordance with 10 CFR 2.790 of the Commission's regulations, a copy of this letter, the enclosures, and your response to this letter will be placed in the NRC Public Document Room.
Sincerely, i
Charles E. Norelius, Director Division of Radiation Safety and Safeguards
Enclosure:
Inspection Report
No. 50-440/89016(DRSS)
.See Attached Distribution
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The Cleveland Electric Illuminating
JUN 0 51989
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Company
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REGION III==
Report No. 50-440/89016(DRSS)
Docket No. 50-440
License No. NPF-58
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Licensee: Cleveland Electric Illuminating Company
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Post Office Box 5000
Cleveland, OH 44101
Facility Name: Perry Nuclear Power Plant, Unit 1
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Inspection At:
Perry Site, Perry, Ohio
Inspection Conducted: May 2 through June 2, 1989
Inspectors:
M. A. Kunowski M. M. [
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R. J. Caniano
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Reviewed By:
M. Schumacher, Chief
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Radiological Controls
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and Chem stry Section
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Approved By:
Robert Greger, Chi f
Reactor Programs Branch
Date
Inspection Summary
Inspection on May 2 throuch June 2, 1989 (Report No. 50-440/89016(DRSS))
Areas Inspected: Special, announced inspection to review allegations of
a possible overexposure.
Results: The inspectors' review of this event indicated that an overexposure
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probably did not occur; however, a potential for one appears to have existed.
The radiation field intensity was not known at the time of entry. Also,
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the worker exited the area without completing his work assignment because he
noted an unexpected SRD reading. The inspectors identified several radiological
control weaknesses attendant to the event, including inadequate surveys in
support of an RWP and a lack of aggressiveness and curiosity by the radiation
protection technicians covering the drywell during the incident. Four
allegations related to the incident were unsubstantiated; two allegations
were substantiated (Sections 2 and 3). Four apparent violations of regulatory
requirements were identified, including (1) inadequate surveys, (2) failure to
document a survey, (3) failure to follow radiological control procedures for
installation of shielding and for initiating a radiological occurrence report,
and (4) failure to use appropriate dosimetry in a high radiation area.
(Sections 2 and 3).
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DETAILS
1.
Persons Contacted
- R. R. Bowers, Corporate Health Physicist
- W. E. Coleman, Manager, Operations Quality Section
' +G. R. Dunn, Lead Engineer, Licensing and Compliance Section, Perry
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Plant Technical Department (PPTD)
- M. W. Gmyrek, Manager, Perry Plant Operations Department
+*H. L..Hegrat, Operations Engineer, Licensing and Compliance Section
J. V. Ivery, Superintendent, R. J. Frazier
- S. F. Kensicki, Director, PPTD
- R. A. Newkirk, Manager, Licensing and Compliance Section
R. W. Parsons, Superintendent, R. J. Frazier
C. Reiter, Health Physics Supervisor, PPTD
T. E. Shega, System Engineer, PPTD
- L. L. VanDerHorst, Plant Health Physicist, PPTD
+*F. C. Whittaker, Lead Health Physics Supervisor, PPTD
- S. J. Wojton, Manager, Radiation Protection Section, PPTD
The inspectors also contacted other licensee employees, including
technicians, workmen, and supervisors.
- G. F. O'Dwyer, NRC Resident Inspector
- Denotes those present at the exit meeting on May 10, 1989.
+ Denotes those present at the exit telephone meeting on June 5, 1989.
2.
Allegation Followup
(Closed) Allegation (AMS No. RIII-89-A-0054)
a.
Allegation Concern No. 1: A worker may have been overexposed during
a job.
An allegation concerning a possible overexposure was received
in the Region III office on April 10, 1989; subsequent telephone
conversations with the alleger were held on April 27, May 11, and
May 31, 1989. The a11eger stated that on March 24, 1989, a worker
may have been overexposed when he was allowed to work in an unexpectedly
high radiation field near a hotspot that was later determined to be
12 R/hr on contact. Several concerns were expressed by the alleger,
namely, that the worker was blamed for the exposure, that the RPM'
may have been covering up the exposure, that the Radiation Work
Permit (RWP) for the job was not properly written, that the hotspot
in the pipe should have been shielded, and that the worker had not
been issued proper dosimetry for the job.
These allegations were reviewed by Region III inspectors during a
special onsite inspection on May 2-3, and May 8-10, 1989 and in
subsequent telephone discussions with licensee representatives
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through June 2, 1989. The inspection consisted of record and
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procedure review, job site observations, and interviews of workers
and licensee technical and management personnel.
Discussion:
On March 24, 1989, at 6:45 p.m., the worker, who is a
pipefitter, and his foreman entered the drywell on RWP 890335 to
provide support for inservice inspection (ISI) work.
Attached
to the RWP were several survey maps for various locations in the
drywell, including the general areas in which the men had to go.
The men stated they notified the radiation protection technicians
(RPTs) at the drywell access control desk before entry, as required
by the RWP, and were told of the radiological conditions in the
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areas in which they had to work, as shown on the survey maps.
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The individuals then entered the drywell and first went to the
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reactor water cleanup (RWCU) system on the 583' elevation.
After
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approximately 30 minutes, the men left this area and went to the
630' elevation to scope another job, removal of pipe supports
(snubbers and pipe clamps) on the low pressure coolant injection
(LPCI) line.
The supports are located about 2' upstream of a LPCI
line check valve in an approximately 3.5' x 5' x 6' pit, adjacent
to, but below, the 630' elevation walkway.
This pit is normally
not accessible from the walkway, being enclosed by jet shielding;
however, some of the jet shielding had been removed on March 22,
1989, allowing access to it.
Within the pit, the foreman recorded some preliminary data and
explained to the worker what had to be done for the job. The men
left the area after approximately 15 minutes (at about 8:00 p.m.)
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and returned to the drywell exit.
As they left the drywell, they
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told the RPTs that they had received approximately 30 mrem, an
unexpected amount, on their SRDs during their short time at the LPCI
job site.
The RPTs attributed this exposure to the time the workers
spent at the RWCU job, where the general area dose rates ranged from
100-150 mrem / hour, and not the LPCI job, where general area dose
rates supposedly ranged from 5-18 mrem / hour, according to the posted
survey, dated May 16, 1989, taken before the jet shielding was removed.
No records were found which showed that a survey of the pit area was
conducted after removal of the jet shielding on March 22 and the
initial pit entry by the workers on March 24.
The RPT who was named in the allegation stated that after the men
lef t he surveyed the pit and identified a 2.5 R/ hour (contact)
hotspot on the LPCI pipe about 3' downstream of the snubbers, and
also measured general area dose rates of 80-100 mR/ hour.
These
general area levels were about a factor of ten higher than those
meawred during the survey of March 16, 1989, which was being used
to allow entry under the RWP.
However, the March 16, 1989, survey
was done with the jet shielding in place and, therefore, did not
properly characterize the radiological conditions in the pit. The
licensee's use of an inappropriate survey to govern RWP entry is an
apparent violation of 10 CFR 20.201(b), which requires the licensee
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to make surveys that are necessary and reasonable to evaluate the
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extent of radiation hazards that may be present
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(No. 440/89016-01a).
In addition, the inspectors determined that the survey identifying.
the 2.5 R/ hour hotspot was not documented, an apparent violation of
the 10 CFR 20.401(b), which requires the. licensee to maintain records
of surveys required by 10 CFR 20.201(b) (No. 440/89016-02).
At 11:45 p.m., the foreman and the worker returned to the drywell,
with a second worker. The RPT stated he informed them of the survey
results including the hotspot.
(However, the worker and the foreman
stated to the inspectors that they were not informed of any hotspot.
The foreman stated that he and the RPT went to the work area, where
the RPT explained that he had surveyed the area earlier in the day
and that dose rates along the bottom of the pipe were 80 mR/ hour
and indicated that general area dose rates were lower.
The worker
stated that the survey results that were relayed to him were general
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area dose rates were 30-40 mR/ hour.)
The worker stated he began the job, assisted by the second worker,
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who did not enter the pit, but' stayed on the 630' walkway to get
tools as needed.
Meanwhile, the foreman, with the agreement of
the RPT, obtained lead shielding and gave it to the workers, who
" hung" it on the pipe near the snubbers.
However, it appears that
the lead shielding was not placed around the pipe elbow, the spot
identified by the RPT as the hot spot, but on a horizontal section
of the pipe near the snubbers.
They continued working until the first worker read his low-range
SRD, and observed what he thought was movement of the SRD hairline.
(Both workers stated to the inspectors that the worker read the SRD
because of his apprehension about the radiation hazards in the area
and not because of such instructions by the RPT.) 'The workers
immediately left the area and went to the drywell exit where they
informed the named RPT of the behavior of the SRD. The worker
estimated that he had been in the pit for 35 to 40 minutes before he-
left.
The RWP record shows 210 mR total dose based on the worker's
low-range SRD; the RPT stated that the worker's high-range SRD
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read 50 mR. The RPT also stated that he told the worker that the
discrepancy may be due to a faulty low-range SRD.
(It was later
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ascribed by health physics management to differences in location
of the two dosimeters with respect to the hotspot.)
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The RPT stated that sometime later he resurveyed the pit with a
different meter and found that the intensity of the hotspot had
increased to 3.5 R/ hour and the general area dose rates had
increased to 300-400 mR/ hour.
The technician then returned to the
drywell exit and informed the workers of the survey results.
(The
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workers claim that when the technician returned, he apologized to
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them saying, in effect,.th'at th'e meter he used for the' previous
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survey must have been defective, and that there was a hotspot in'the
elbow of the pipe and general area dose rates were 300-400 mR/ hour.
The workers then left the drywell, at about 12:30 a.m., on March 25,
1989.
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Another foreman (the general foreman) stated.to the inspectors
that after hearing of the hotspot, he borrowed.a Bicron Model
Tech 50 G-M survey meter from the RPTs at the drywell control-
desk and surveyed the elbow.
He. stated that'he measured 5 R/ hour.
on. contact with the elbow (5 R/ hour is the highest' value obtainable
with this model survey meter.)
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According to the technician, after he informed the workers of the:
survey results he informed his_ supervisor of the apparent change-
in the radiological conditions in the-pit.
Subsequently, no further
entries were allowed, pending an ALARA review.. The RPT documented
his survey approximately 30 minutes later, at 1:00 a.m. 'There
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is no record of the survey by the general foreman.
During his next shift (on Saturday night, March 25th), the RPT-
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stated that he again surveyed the work area in the pit and datermined
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that the hotspot was now reading 12 R/ hour and'the eneral area dose
rate was 1 R/ hour.
For this survey, the RPT climbed own into the
pit, whereas, for the two previous surveys, he did not anter the pit,
but just reached in with his meter from the walkway.. An inspection-
of the work area by an NRC inspector indicated that because of the
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narrow, partially obstructed opening to the area, and the position
of the 12" LPCI pipe in the pit, an adequate survey of the work area
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could not have been made from the walkway with the type of survey
meter used by the technician._ Performing the two surveys of the
pit from the walkway is another instance of an apparent violation
of 10 CFR 20.201(b), which requires the licensee to make surveys
that are reasonable to evaluate the extent of radiation hazards
that may be present (No. 440/89016-Olb).
On his next shift, (Saturday-Sunday, March 25-26), the worker
discussed the incident with an HP supervisor who took the' worker's
TLD for processing, and began an investigation to determine if an
overexposure had occurred.
Later, the worker discussed the incident
with the HP supervisor responsible for external dosimetry on
nightshift. This supervisor apparently tried to allay some of the
worker's concerns, and provided, at the worker's request, a
preliminary dose estimate that ranged from 210 stem to 7000 mrem.
The 210 mrem value was the. worker's recorded dose for the job
according to the low-range SRD and the 7000 mrem value was a
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worst-case estimate assuming the worker was in contact with a
3.5 R/ hour hotspot for the entire 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> he spent in the drywell.
The supervisor then refined the estimate by-assuming 20% of the time
was spent in transit to and from the work area,'and explained to
the worker that even this simple assumption would change the upper-
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estimate from 7 rem to 4.76 rem.
(The supervisor stated in a memo-
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dated March 26, 1989, that he later realized that he miscalculated
the value, noting that 80% of 7 rem is 5,6 rem, not 4.76 rem.) After
discussing this estimate and general information on the effects of
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radiation, the supervisor and the worker then discussed other
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details of the job.
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During the remainder of the week, the plant HP staff made a more
formal evaluation of the potential doses to the worker and the
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foreman.
The evaluation used personal dosimetry results, a detailed
survey of the work area, and times and distances obtained from a
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reenactment of the job in the dose reconstruction.
The reenactment
was performed in the pit using an HP supervisor of similar height
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as a surrogate for the worker. The reconstruction for the worker
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assumed:
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(1) The head 12 inches from the hotspot for 26.5 minutes in a' field
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of 500 mR/hr;
(2) The head 9 inches from the hotspot for 26.5 minutes in a field
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of 1000 mR/hr; and
(3) The head 3 inches from the hotspot for two minutes in a field
of 3500 mR/hr.
(According to licensee representatives, distances referenced for the
dose rates were measured from the pipe.to the center of the detector
which is located approximately 1 1/2 inches from the base of.the
survey meter.)
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The resulting dose estimate to the head of the worker was 780 mrem
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for his two entries into the pit.
A similar but more detailed
scenario was used to estimate 346 millirems for the foreman's
entries (17 minutes) into the pit.
The corporate health physicist
made independent dose estimates based on the worker's dosimeter
readings and allowing for attenuation through the body but using the
same dose rate-time scenario.
He obtained 750 and 860 mrem for the
worker's high and low range dcsimeters, respectively, which are not
significantly different from the 780 mrem estimated by the station
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staff.
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The reconstruction was necessitated by the absence of dosimetry on
the portion of the total body (the head or top of the back) nearest
the hotspot.
The reconstruction for the foreman appears better
because it was based on his detailed written description of his
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actions and assumes a short period in contact with the pipe. The
reconstruction for the worker assumed no contact time despite the
worker's assertion that he leaned against the pipe (although not
necessarily the hot spot). An NRC inspector who entered the pit
noted that it was neither difficult nor ' awkward to place his head
on the LPCI pipe. The worker told NRC representatives that he was
not sure of time or positions with reference to the hotspot.
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While the licensee's dose estimate of 780 mrem for the worker may
be a reasonably good estimate of his actual dose, there is an
uncertainty associated with this estimate due to the worker's stated
lack of specific recollection of his body movements in the pit.
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However, because the worker did not recall having his head in
contact with the pipe for a significant length of time, it does not
appear that even under conservatively assumed conditions, he could
have received a dose in excess of regulatory limits.
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Finding: This allegation could not be substantiated.
It appears,
based on the results of this inspection, that no overexposure
occurred although the worker's dose may have been underestimated
by assuming that no time was spent in direct contact with the
hotspot.
However, a potential for an overexposure did exist and
an overexposure may have occurred if the Worker had not left the
work area when he did and/or if the hotspot radiation levels had
been higher. Two apparent violations of NRC requirements were
identified.
b.
Allegation Concern No. 2: The RPM told the worker that the exposure
was the worker's fault.
Discussion:
The RPM denied making a statement of this nature to the
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worker.
The RPM stated to the inspectors that while discussing the
incident with the worker and hearing comments from the worker
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cot.erning how many times he questioned the RPTs about the dose
rates in the area that he (the RPM) did ull the worker that if he
was not satisfied with the answers he was getting from the techs
that he should have pursued the matter at a higher level, as allowed
and encouraged by station policy.
Findings:
The RPM made a statement that could be interpreted as
ascribing fault to the worker; however, the RPM denied that was the
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intention.
The allegation was not substantiated.
No violations of
HRC requirements were identified.
c.
Allegation Concern No. 3:
The alleger stated that he was concerned
that the RPM may be covering up the alleged overexposure because the
RPM would not allow the worker to see or copy r.ny of the records
pertaining to the incident, and because of the RPM's statement that
he (the RPM) "never had anyone burned out at ?erry" and that he
would evaluate the dose and "it will probab13 be under 1000 mR."
This concern was reinforced by the fact that Tnother HP supervisor
had earlier given him an exposure estimate of !.78 rem (The
licensee's memo of March 26, 1989 refers to thi; estimate as
4.76 rem.
See Allegation Concern No. 1.)
Discussion: The RPM stated to the inspectors that the worker
requested to review or receive copies of some records but that
he declined because the evaluation was not yet complete. The RPM
stated that the worker was told that copies could be requested after
completion of the evaluation. On May 2, 1989, the RPM told the
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inspectors that the evaluation had been completed but no request.
from the worker had been received.
He further stated that he had
no reason to deny the worker's request and, in fact, had responded
to a similar request from the foreman for his records.
He added
that such detailed records are not normally given to workers.
The RPM told the inspectors that he did not remember making the
statement that he "never had anyone burned out at Perry," but stated
that he did tell the worker that it was not Perry's policy to " burn
out" workers; but rather it was Perry's policy to minimize dose to
the individual and to groups of workers, and to equally distribute
dose as much as possible.
He also stated that his forecast of under
1000 mR was based on his knowledge of the tentative results of the
evaluation then in progress, which was much more plausible than the
crude 4.76 rem estimate made before detailed measurements were taken
in the pit.
Findings: The inspectors could not substantiate the allegation
that the RPM was concealing information from the worker regarding
]
the worker's exposure. The RPM acknowledged that records of the
incomplete evaluation were not given to the worker but stated that
the worker was told.he could request a copy of the evaluation when
completed.
No violations of NRC requirements were identified.
)
{
d.
Allegation Concern No. 4: The Radiation Work Permit (RWP) for the
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job on which the alleged overexposure occurred was not properly
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written.
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Discussion: The alleger stated that he was told by the ALARA
Coordinator (name unknown) that the HP department " screwed up the
RWP." The inspectors interviewed the members of the ALARA staff,
including the dayshift and nightshift ALARA Coordinators, and
several ALARA Specialists.
The nightshift ALARA Coordinator
remembered being questioned by an individual unknown to him about
the incident but stated that he did not remember making such a
statement about the RWP to the individual, and probably would not
have made such a statement.
RWP No. 890335, written March 1, 1989,
covered in-service inspection and support work which included snubber
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removal in the pit. The RWP covered such work, throughout the
drywell.
It specified that HP be notified before the start of work
so that area conditions may be established and also required either
HP coverage or a dose rate meter to enter a high radiation area
(HRA).
The entire drywell was posted as an HRA with control over
entry exercised at the HP. desk at its entrance where the RWP sign-in
sheets are kept.
In this case, area conditions were established not
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from a survey at the the of entry on March 24, but from the record-
of a' survey made on March 16, as noted-in the discussion under
Allegation Concern No. 1, this survey was inadequate because it did
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not accurately depict conditions in the pit at the time of entry.
Finding:
The RWP, although very generally written, was adequate to
prevent this occurrence had it been followed; therefore the
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allegation was unsubstantiated.
However, overall radiological
control was vitiated due to inadequate surveys to estchlish
radiological conditions, as described under Allegation Concern
No. 1.
e.
Allegation Concern No. 5: A pipe with a hotspot should have been
shielded during the work in the area.
Discussion:
Station practice is to shield or flush hotspots before
allowing work to proceed and if not practical, then to use other
.
means to limit worker exposure such as restricting staytime or using-
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alarming dosimeters.
The opportunity to use such controls before
work in the pit began on March 24 was missed due to the inadequate
survey previously discussed.
Also, the controls were not imposed
<
before worker reentry following discovery of the 2.5 R/hr hotspot.
Shielding was hung by the workers after reentry, at about 11:45 p.m.
However, it was not hung in accordance with Perry Administrative
Procedure PAP-0122, " Selection and Use of Temporary Shielding,"
which requires completion of a request form PPNP No. 6623 and
an estimate by the ALARA Coordinator of the person-rem that would
be incurred if the shielding were not installed.
Failure to
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follow this procedure is an apparent violation of Technical
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Specification 6.11.1 which requires adherence to procedures for
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personnel radiation protection (Violation 440/89016-3a).
Finding:
This allegation is substantiated.
Although licensee
procedures were vague on this point, good ALARA practice would have
dictated shielding the hotspot before work began in the pit; that
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it was not hung then is an apparent result of the inadequate survey.
When it was hung, it was done so improperly.
One apparent violation
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was identified.
f.
Allegation Concern No. 6:
Dosimetry should have been placed on the
worker's head while working near the hotspot.
Discussion:
Based on discussions with the worker and the foreman, a
reenactment of the job, and survey information, it is apparent that
a steep dose gradient existed in the work area, and that the highest
dose during the job would have been to the head and upper back,
not the chest where the dosimetry was placed.
The dosimeters
near the chest would have been subject to shielding from the worker's
body, whereas a dosimeter on the head or upper back would not.
Therefore, the dose recorded by the dosimeter near or on the chest
would be inaccurate.
So too would the dose determined by
back-calculation from the dosimeter because of uncertainties in
position of the chest with respect to the source and because of
the varying shielding effect as the worker moved around in the
work area. 10 CFR 20.202(a)(3) requires each licensee to supply
appropriate personnel monitoring equipment to each individual
who enters a high radiation area.
In apparent violation of this
requirement, the licensee did not supply appropriate personnel
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monitoring equipment to the two workers who entered the pit, a high
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radiation area, in that dosimetry was not placed on the part of
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the whole body subject to the highest dose (No. 440/89016-04).
Findings:
The allegation was substantiated.
One apparent violation
of NRC requirements was identified.
3.
Licensee Performance
This event revealed weaknesses in the licensee's radiological controls;
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most notable was the failure to adequately survey to determine
radiological conditions attendant upon entry to the work area.
This was
significant because the controlling RWP was generally written, leaving
radiological details to be determined by site-specific surveys.
An
adequate survey taken at entry should have resulted in identification of
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elevated radiation levels, an ALARA review,. better worker instructions,
and issuance of proper dosimetry such that the incident would have been
avoided. An inadequate survey tends to undermine the RWP system of
controls.
,
A related and perhaps more fundamental weakness was the apparent lack of
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curiosity by the radiation protection group covering the drywell work on
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Harch 24-25, 1989, when the exiting workers first expressed concern about
their SRD readings and again after the 2.5 R/ hour hotspot was identified.
Opportunities to avoid an incident were again lost due to lack of
aggressive response by the radiation protection group.
!
Lack of aggressiveness also appeared to be a weakness in the licensee's
followup investigation of the event.
Problems identified by the
inspectors included the following.
The licensee did not begin an investigation of this' event until
the worker sought out an HP supervisor on the worker's next shift
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(Saturday-Sunday, March 25-26) with complaints concerning the
event.
The foreman was not interviewed until two days after the
,
incident (on Monday, March 27,1989), when he also sought out an
,
HP supervisor.
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The licensee's investigation was too narrowly focused and did not
include other relevant documents such as the work order covering
the worker and his foreman and the HP drywell logbook.until their
relevance was pointed out by the inspectors.
Both of these records
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indicated that other workers involved in snubber related work had
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entered the same general area; however, subsequent licensee review
of these entries indicated they were not in close proximity to the
hotspot.
The licensee had in place two procedures for conducting and-
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documenting a thorough review which had not been invoked at the
time of the inspection.
Perry Administrative Procedure, PAP-0124,
" Radiological Occurrence Reporting," should have been implemented
,
by initiation of a Radiological Occurrence Report (ROR) shortly -
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after the event. This procedure (Section 5.1) defines a
radiological occurrence as "an event which results in or could
I
result in a violation of the intent of Perry radiologic:1
procedures, practices, or policies; or personnel r:diation exposures
in excess of administrative guides and 10 CFR 20 limits " The
procedure also states (Section 3.4) " Individuals are responsible
for reporting radiological occurrences in a timely manner." Contrary
to this requirement, and thus in apparent violation of Technical Specification 6.11.1, no ROR was initiated for this incident
although it violated the intent of Perry radiological procedures,
practices, and policies on ALARA and external exposure control
(No.440/89016-03b).
An example of an apparent violation of NRC requirements was identified.
4.
Exit Interview
An exit interview was conducted with licensee representatives (Section 1)
on May 10, 1989, to discuss the tentative findings and possible
enforcement options. The inspector stated that although the event may
not have resulted in an overexposure, a significant potential did exist
for one. The inspector also identified several apparent violations
including inadequate evaluation, failure to document a survey,
]
unauthorized shielding placement, and failure to initiate an R0R. The
licensee stated that a condition repc-t (which has a higher threshold than
an ROR) was being initiated. The licensee did not identify any material
reviewed by the inspectors as proprietary.
A telephone conversation was held with the licensee representatives
(denoted in Section 1) on June 5, 1989, to discuss the inspection
findings including apparent violations. The following matters were
specifically addressed:
a.
NRC determination that an overexposure apparently did not occur,
but that there may have been a substantial potential for one,
b.
Other specific allegation findings.
c.
Apparent violations for inadequate surveys (Section 2.a), for failure
to document a survey (Section 2.a), for installation of temporary
shielding and for failure to initiate a radiological occurrence
report both contrary to procedure (Sections 2.e and 3), and failure
to use appropriate dosimetry in a high radiation area (Section 2.f).
d.
Weaknesses in radiological controls related to the incident and in
the licensee's followup.
e.
Confirmed the receipt of the list of topics to be specifically
addressed at the Enforcement Conference, and the time, date, and
location of the Enforcement Conference.
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