Information Notice 1986-44, Failure to Follow Procedures When Working in High Radiation Areas

Failure to Follow Procedures When Working in High Radiation Areas

ML031250056
Person / Time
Site:	Beaver Valley, Millstone, Hatch, Monticello, Calvert Cliffs, Dresden, Davis Besse, Peach Bottom, Browns Ferry, Salem, Oconee, Mcguire, Nine Mile Point, Palisades, Palo Verde, Perry, Indian Point, Fermi, Kewaunee, Catawba, Harris, Wolf Creek, Saint Lucie, Point Beach, Oyster Creek, Watts Bar, Hope Creek, Grand Gulf, Cooper, Sequoyah, Byron, Pilgrim, Arkansas Nuclear, Three Mile Island, Braidwood, Susquehanna, Summer, Prairie Island, Columbia, Seabrook, Brunswick, Surry, Limerick, North Anna, Turkey Point, River Bend, Vermont Yankee, Crystal River, Haddam Neck, Ginna, Diablo Canyon, Callaway, Vogtle, Waterford, Duane Arnold, Farley, Robinson, Clinton, South Texas, San Onofre, Cook, Comanche Peak, Yankee Rowe, Maine Yankee, Quad Cities, Humboldt Bay, La Crosse, Big Rock Point, Rancho Seco, Zion, Midland, Bellefonte, Fort Calhoun, FitzPatrick, McGuire, LaSalle, 05000000, Zimmer, Fort Saint Vrain, Shoreham, Satsop, Trojan, Atlantic Nuclear Power Plant, Skagit, Marble Hill
Issue date:	06/10/1986
From:	Jordan E NRC/IE
To:
References
IN-86-044, NUDOCS 8606040010
Download: ML031250056 (5)

LIS ORIGINAL SSINS No.: 6835 IN 86-44 UNITED STATES

NUCLEAR REGULATORY COMMISSION

OFFICE OF INSPECTION AND ENFORCEMENT

WASHINGTON, D.C. 20555 June 10, 1986 IE INFORMATION NOTICE NO. 86-44: FAILURE TO FOLLOW PROCEDURES WHEN WORKING

IN HIGH RADIATION AREAS

Addressees

All nuclear power reactor facilities holding an operating license (OL) or a

construction permit (CP) and research and test reactors.

Purpose

This information notice is provided to alert licensees of the problem of

recurring, unauthorized entries by maintenance workers into high radiation

areas. A recent event is discussed below, and a related event is summarized in

Attachment 1. Since the workers ignored and bypassed maintenance procedures

that include radiological controls established to limit exposures in high

radiation areas, it is fortuitous that during these entries no personnel

exposure limits were exceeded.

It is expected that recipients will review this notice for applicability to

their facilities' work controls programs and consider actions, if appropriate, to preclude the occurrence of a similar problem at their facilities. Sugges- tions contained in this information notice do not constitute NRC requirements

and, therefore, no specific action or written response is required.

Past Related Correspondence:

INPO Significant Event Report (SER) 50-85, "Uncontrolled Personnel Radiation

Exposure," November 4, 1985 (discusses two events).

INPO Significant Operating Experience Report (SOER) 85-3, "Excessive Personnel

Radiation Exposures," April 30, 1985 (discusses seven events).

IE Information Notice No. 84-19, "Two Events Involving Unauthorized Entries

Into PWR Reactor Cavities," March 21, 1984.

IE Information Notice No. 84-59, "Deliberate Circumventing of Station Health

Physics Procedures," August 6, 1984 (discusses six events).

8606040010

IN 86-44 June 10, 1986

Description of Circumstances

On January 8, 1986, at Turkey Point, an instrument and controls (IC)technician

made an unaccompanied, unauthorized entry into a high radiation area to com- plete repairs on the traversing incore probe (TIP) drive unit with an irradi- ated TIP withdrawn into the work area. Earlier that same day, with a health

physics (HP) technician providing job coverage, the IC technician had made

adjustments to the TIP drive unit (dose rates only 5 to 25 mR/hr), which later

enabled the technician to successfully withdraw the TIP into the accessible TIP

drive work area.

During the unauthorized entry, the IC technician received 500 millirem whole

body exposure during an approximately 5-minute stay time in a work area, which

was later calculated to be 6 R/hr in the general area. The radiation level 1 foot away from the work area was 65-70 R/hr on contact with the tubing contain- ing the irradiated TIP. The low-range Geiger-Mueller (GM) portable survey

instrument (scale of 0-1 R/hr) used by the IC technician upon entering the high

radiation area initially moved up the scale to 800 mR/hr and then reportedly

went rapidly down the scale to zero, when moved closer the the radiation

source. The IC technician failed to recognize the malfunctioning survey

instrument and stayed in the area to complete his maintenance task. At these

dose rates, it was fortuitous that the technician did not remain in the TIP

area for any longer period.

Subsequent licensee and NRC regional review of the event revealed several key

factors that contributed to the incident.

1. Failure To Follow Procedures

Numerous procedural violations occurred before and during the unauthorized

entry. These violations included failure to notify HP personnel before

operating the TIP, performing craft work outside the scope of the author- ized plant work order (PWO), and making entry and working alone on the TIP

system.

2. Personnel Shortcomings

The IC technician's foreman failed to clearly define the TIP system problem

and provide adequate instructions on the PWO. The IC technician failed to

obey the local radiological area warning, a posting that read "high

radiation area - keep out." Inadequate training caused the IC technician

to fail to recognize a malfunctioning survey instrument (downscale reading

caused by GM detector tube continuous discharge response to intense

radiation levels), which he was using to help control his exposure.

The NRC noted subsequent to the event that, although not contributory to this

incident, governing maintenance procedures for the TIP system did not require

tagging out of other operable TIPs (to prevent inadvertent withdrawal into an

occupied work area) with work in progress on a malfunctioning TIP unit. For

future TIP work, the licensee agreed to control movement of the irradiated TIPs

with equipment tag out controls.

IN 86-44 June 10, 1986 Discussion:

The NRC continues to note repeated occurrences of unauthorized entries into

high radiation areas (see Past Related Correspondence). In most of the indi- vidual events discussed in these documents and the two events in this notice, failure of personnel to adhere to existing work/control procedures or radiation

work permits (RWP), or both, is a central cause of the exposure incidents.

Adherence to work/surveillance procedures forms a basic framework for providing

effective, consistent radiological controls for work in high radiation areas.

Short of providing direct, continuous health physics coverage for each and

every task, these procedures serve as the formal mechanism for initiating

necessary communications between various plant worker crafts groups and the

health physics support group. This communication results in appropriate

radiological support (e.g., RWP issuance) for the maintenance/surveillance

activities. Bypassing these procedures and thus failing to comply with the

radiological precautions in them seriously weakens the health physics control

program established to protect the workers. It is the licensee's responsibil- ity to ensure that these procedures are adhered to.

To emphasize the importance of workers properly performing work activities in

high radiation areas, appropriate enforcement action has been proposed for the

Turkey Point event (proposed $50,000 civil penalty).

No specific action or written response is required by this information notice.

If you have any questions about this matter, please contact the Regional

Administrator of the appropriate regional office or this office.

dwario Jor D , irector

Division of Emergency Preparedness

and Engineering Response

Office of Inspection and Enforcement

Technical Contacts: James E. Wigginton, IE

(301) 492-4967 Roger L. Pedersen, IE

(301) 492-9425 Attachments:

1. Related Exposure Event

2. List of Recently Issued IE Information Notices

Attachment 1 IN 86-44 June 10, 1986 RELATED EVENT SUMMARY

At the Cooper Nuclear Station on August 28, 1985, two IC technicians performed

maintenance (TIP alignment) as required by a craft work procedure. Contrary to

the work procedure's radiological-cautions warnings, these workers failed to

obtain a special RWP and entered the TIP drive enclosure housing, ignoring the

access posting, "Notify Health Physics Prior to Opening." The TIP maintenance

procedure further warned that the drive unit's Gleason reel is spring loaded

and the incore detector could be withdrawn by the spring tension. It further

warned that the withdrawn incore detector probe could be highly radioactive.

Upon opening the unsurveyed enclosure, they found the TIP had withdrawn into

the enclosure and the detector had broken off. The technicians immediately

exited the high radiation and high airborne radioactivity area. The indivi- duals each received approximately 200 mrem whole body exposure and airborne

intakes of 44 and 90 MPC-hrs.

As corrective actions, the licensee (1) stressed to all station personnel the

importance of properly following radiological controls and (2) revised the

governing maintenance procedure to require written documentation (signoff)

notifying HP before working on the TIP system.

Attachment 2 IN 86-44 June 10, 1986 LIST OF RECENTLY ISSUED

IE INFORMATION NOTICES

Information Date of

Notice No. Subject Issue Issued to

86-43 Problems With Silver Zeolite 6/10/86 All power reactor

Sampling Of Airborne Radio- facilities holding

iodine an OL or CP

86-42 Improper Maintenance Of 6/9/86 All power rector

Radiation Monitoring Systems facilities holding

an OL or CP

86-41 Evaluation Of Questionable 6/9/86 All byproduct

Exposure Readings Of Licensee material licensees

Personnel Dosimeters

86-32 Request For Collection Of 6/6/86 All power reactor

Sup. 1 Licensee Radioactivity facilities holding

Measurements Attributed to an OL or CP

The Chernobyl Nuclear Plant

Accident

86-40 Degraded Ability To Isolate 6/5/86 All power reactor

The Reactor Coolant System facilities holding

From Low-Pressure Coolant an OL or CP

Systems in BWRS

86-39 Failures Of RHR Pump Motors 5/20/86 All power reactor

And Pump Internals facilities holding

an OL or CP

86-38 Deficient Operator Actions 5/20/86 All power reactor

Following Dual Function Valve facilities holding

Failures an OL or CP

86-37 Degradation Of Station 5/16/86 All power reactor

Batteries facilities holding

an OL or CP

86-36 Change In NRC Practice 5/16/86- All power reactor

Regarding Issuance Of facilities holding

Confirming Letters To an OL or CP

Principal Contractors

OL = Operating License

CP = Construction Permit