Information Notice 1993-69, Radiography Events at Operating Power Reactors
UNITED STATES
NUCLEAR REGULATORY COMMISSION
OFFICE OF NUCLEAR REACTOR REGULATION &
OFFICE OF NUCLEAR MATERIAL SAFETY AND SAFEGUARDS
WASHINGTON, D.C.
20555
September 2, 1993
RADIOGRAPHY EVENTS AT OPERATING POWER REACTORS
Addressees
All holders of operating licenses or construction permits for nuclear power
reactors and all radiography licensees.
Purpose
The U.S. Nuclear Regulatory Commission (NRC) is issuing this information
notice to alert licensees to three events involving radiography at operating
nuclear power plants.
It is expected that recipients will review the
information for applicability to their facilities and consider actions, as
appropriate, to avoid similar problems.
However, suggestions contained in
this information notice are not NRC requirements; therefore, no specific
action or written response is required.
Description of Circumstances
During three events in late 1992 and early 1993, employees at nuclear reactor
facilities circumvented controls established to ensure the safe conduct of
radiography. In each event, licensee personnel made unauthorized entries into
areas where radiography was either just about to occur or in progress. No
significant exposures resulted from these events; however, such events
indicate a potential for significant exposures.
Zion Event
On December 9, 1992, an operatv, on routine rounds in the auxiliary building
entered an area that was temporarily roped off and posted with a sign that
read, "High Radiation Area; Radiography In Progress; Exclusion Area; Do Not
Enter." The operator had read and signed a radiation work permit that allowed
entry into high radiation areas normally encountered during operator rounds
and felt that he was authorized to enter the area.
However, Zion Station
procedures require the use of a specific radiation work permit to enter areas
in which radiography is taking place.
Once inside the area, the operator
encountered the radiographer who had just finished setting up his equipment
and was doing a final boundary check. The radiographer noted he was not
authorized to enter this area and escorted the operator from the radiography
area.
Subsequent interviews with the operator indicated that he was unaware
of the significant radiological hazards associated with radiography.
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September 2, 1993 Kewaunee Event
On March 27, 1993, a licensee supervisor made an unauthorized entry into an
area in the turbine building that was temporarily roped off and posted with a
sign that read "Radiation Area; Danger - Keep Out; Radiography In Progress;
Contact Health Physicist Prior To Entry." The supervisor was obtaining
temperature data in the area and had not read or signed the appropriate
radiation work permit nor was he wearing proper dosimetry for the restricted
area. After obtaining his data, he was observed leaving the area by Health
Physics personnel who were responsible for watching the boundary while
radiography was in progress.
The Health Physics personnel were watching a
different boundary when the licensee supervisor entered the unauthorized
radiography area.
Subsequent interviews with the individual indicated that he
did not stop and read the sign.
The licensee dose estimate indicated that the
individual received an approximate dose of 0.001 mSv [0.1 mrem].
Dresden Event
About 11:00 p.m. on February 13, 1993, two workers made an unauthorized entry
into a posted radiologically controlled area established for radiography in
the Unit 1 high-pressure coolant injection building.
The two radiographers
and the radiation protection technician involved with the radiography were on
a meal break at the time of the entry.
After the break, the radiographers and
the radiation protection technician returned to the radiological controlled
area, without verifying the area was free of personnel.
Radiography was
resumed and after 5 minutes of a 6 minute exposure had elapsed, the
radiographers observed the two workers leaving the area.
In its review of the
event, the licensee determined that the two workers disregarded the postings
and intentionally entered the area to hold a personal conversation in a room
on the second floor of the building.
Both workers were wearing
thermoluminescent dosimeters but had not signed the appropriate radiation work
permit for the radiography area.
The route to the second floor led through
the first-floor room where the radiography source was located, but was some
distance away from the source.
The licensee determined that doses of 0.15 mSv
[15 mrem] and 0.30 mSv [30 mrem] were received by the two individuals.
The
two individuals received disciplinary action from the licensee.
Discussion
Radiography sources can create radiation fields in which permissible
occupational dose standards can be exceeded in a short period of time.
Although doses were low in the three events described above, each could have
resulted in more serious exposures had the timing been different or had
personnel been closer to the radiography source.
Appropriate enforcement
actions have been taken against the licensees as a result of the events.
In
q /
September 2, 1993
an effort to improve control during radiography, licensees have taken the
corrective actions, including some of the following, as a result of their
review of and lessons learned from the events.
(1) Heightened employee awareness of the potential hazards associated with
radiography through the use of station newsletters.
(2) Enhanced general employee training to ensure that licensee employees
receive information describing the radiological hazards associated with
radiography and radiography controls.
(3) Emphasized to licensee employees the importance with regard to safety of
obeying radiological procedures, signs, and warnings.
This information notice requires no specific action or written response. If
you have any questions about the information in this notice, please contact
the technical contacts listed below or the appropriate Office of Nuclear
Reactor Regulation project manager.
Carl J. Paperiello, Director
Division of Industrial
and Medical Nuclear Safety
Office of Nuclear Material Safety
and Safeguards
Brian K. Grimes, Director
Division of Operating Reactor Support
Office of Nuclear Reactor Regulation
Technical contacts:
William G. Snell, RiII
(708) 790-5513
John B. Carrico, NMSS
(301) 504-2634 Attachments:
1. List of Recently
2.
List of Recently
Issued NMSS Information Notices
Issued NRC Information Notices
I-
Attachment 1
September 2, 1993 LIST OF RECENTLY ISSUED
NMSS INFORMATION NOTICES
Information
Notice No.
Subject
Date ot
Issuance
Issued to
93-60
93-50
93-36
93-31
93-30
93-19
93-18
93-14
93-10
Reporting Fuel Cycle and
Materials Events to the
NRC Operations Center
Extended Storage of
Sealed Sources
Notifications, Reports, and Records of Misadmin- istrations
Training of Nurses
Responsible for the
Care of Patients with
Brachytherapy Implants
NRC Requirements for
Evaluation of Wipe
Test Results; Cali- bration of Count Rate
Survey Instruments
Slab Hopper Bulging
Portable Moisture-Density
Gauge User Responsibilities
during Field Operations
Clarification of
10 CFR 40.22, Small
Quantities of Source
Material
Dose Calibrator Quality
Control
08/04/93
07/08/93
05/07/93
04/13/93
04/12/93
03/17/93
03/10/93
02/18/93
02/02/93
All fuel cycle and materials
licensees.
All licensees authorized
to possess sealed sources.
All U.S. Nuclear Regulatory
Commission medical
licensees.
All U.S. Nuclear Regulatory
Commission medical
licensees.
All U.S. Nuclear Regulatory
Commission medical
licensees.
All nuclear fuel cycle
licensees.
All U.S. Nuclear Regulatory
Commission licensees that
possess moisture-density
All Licensees who possess
source material.
All Nuclear Regulatory
Commission medical
licensees.
K)~1
Attachment 2
September 2, 1993 LIST OF RECENTLY ISSUED
NRC INFORMATION NOTICES
Information
Notice No.
Sub;
Date ot
Issuance
ject
Issued to
93-68
92-16, Supp. 2
93-67
93-66
93-65
93-64
93-63
93-62
Failure of Pump Shaft
Coupling Caused by
Temper Embrittlement
during Manufacture
Loss of Flow from the
Pump during Refueling
Cavity Draindown
Bursting of High
Pressure Coolant
Injection Steam Line
Rupture Discs Injures
Plant Personnel
Switchover to Hot-Leg
Injection Following
A Loss-of-Coolant
Accident in Pres- surized Water Reactors
Reactor Trips Caused
by Breaker Testing
with Fault Protection
Bypassed
Periodic Testing and
Preventive Maintenance
of Molded Case Circuit
Breakers
Improper Use of Soluble
Weld Purge Dam Material
Thermal Stratification
of Water in BWR Reactor
Vessels
09/01/93
08/23/93
08/16/93
08/16/93
08/13/93
08/12/93
08/11/93
08/10/93
All holders of OLs or CPs
for nuclear power reactors.
All holders of OLs or CPs
for nuclear power reactors.
All holders of OLs or CPs
for nuclear power reactors.
All holders of OLs or CPs
for pressurized water
reactors.
All holders of OLs or CPs
for nuclear power reactors.
All holders of OLs or CPs
for nuclear power reactors.
All holders of OLs or CPs
for nuclear power reactors.
All holders of OLs or CPs
for boiling water reactors.
OL = Operating License
CP = Construction Permit
IN 93-69 September 2, 1993 an effort to improve control during radiography, licensees have taken the
corrective actions, including some of the following, as a result of their
review of and lessons learned from the events.
(1) Heightened employee awareness of the potential hazards associated with
radiography through the use of station newsletters.
(2) Enhanced general employee training to ensure that licensee employees
receive information describing the radiological hazards associated with
radiography and radiography controls.
(3) Emphasized to licensee employees the importance with regard to safety of
obeying radiological procedures, signs, and warnings.
This information notice requires no specific action or written response. If
you have any questions about the information in this notice, please contact
the technical contacts listed below or the appropriate Office of Nuclear
Reactor Regulation project manager.
Olina! Kivnpd hv
Carl J. Paperiello, Director
Division of Industrial
and Medical Nuclear Safety
Office of Nuclear Material Safety
and Safeguards
Brian K. Grimes, Director Brian K. rH-¢
Division of Operating Reactor Support
Office of Nuclear Reactor Regulation
Technical contacts: William G. Snell, RIII
(708) 790-5513
John B. Carrico, NMSS
(301) 504-2634 Attachments:
1. List of Recently Issui
2. List of Recently Issui
- SFF PRFVTOUS CONCURRENCE
ld NMSS Information Notices
ld NRC Information Notices
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NAME
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DATE
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Document Name:
93-69.IN
- Electronic concurrence
- Projects has reviewed this information notice
Zion - Clyde Shiraki
Kewaunee -
Richard Laufer
Dresden - Peter Erickson
- ' '**NMSS, Industrial, Medical
Nuclear Safety
Division Director
C.J. Paperiello
08/10/93
IN 93-xx
August xx, 1993 (1) Heightened employee awareness of the potential hazards associated with
radiography through the use of station newsletters.
(2) Enhanced general employee training to ensure that licensee employees
receive information describing the radiological hazards associated with
radiography and radiography controls.
(3) Emphasized to licensee employees the importance with regard to safety of
obeying radiological procedures, signs, and warnings.
This information notice requires no specific action or written response.
If
you have any questions about the information in this notice, please contact
the technical contact listed below or the appropriate Office of Nuclear
Reactor Regulation project manager.
Carl J. Paperiello, Director
Division of Industrial
and Medical Nuclear Safety
Office of Nuclear Material Safety
and Safeguards
Brian K. Grimes, Director
Division of Operating Reactor Support
Office of Nuclear Reactor Regulation
Technical Contact:
William G. Snell, Region III
(708) 790-5513
John B. Carrico, NMSS
(301) 504-2634 Attachment:
1.
2.
List of Recently Issued NMSS Information Notices
List of Recently Issued NRC Information Notices
- SEE PREVIOUS CONCURRENCE
OFF
- REGION III
- TECH ED
- PRPB:NRR
- NRR:DRSS:D
- OGCB:DORS
NAME
WGSnell
MMejac
LJCunningham
FJCongel
NECampbell
DATE
07/08/93
07/21/93
08/03/93
08/10/93
07/30/93 C:OGCB:DOIW/
- D: IMNS
D:DORS
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Document Name:
IN-RADGR.PHY
- Electronic concurrence
- Projects has reviewed this
Zion -
Clyde Shiraki
Kewaunee - Richard Laufer
Dresden - Peter Erickson
information notice
- NMSS, Industrial, Medical
Nuclear Safety
Division Director
C.J. Paperiello
08/10/93
K- ,
IN 93-xx
August xx, 1993 (1) Heightened employee awareness of the potential hazards associated with
radiography through the use of station newsletters.
(2) Enhanced general employee training to ensure that licensee employees
receive information describing the radiological hazards associated with
radiography and radiography controls.
(3) Emphasized to licensee employees the importance with regard to safety of
obeying radiological procedures, signs, and warnings.
This information notice requires no specific action or written response. If
you have any questions about the information in this notice, please contact
the technical contact listed below or the appropriate Office of Nuclear
Reactor Regulation project manager.
Brian K. Grimes, Director
Division of Operating Reactor Support
Office of Nuclear Reactor Regulation
Technical Contact:
Attachment:
List
William G. Snell, Region III
(708) 790-5513 of Recently Issued NRC Information Notices
- SEE PREVIOUS CONCURRENCE
OFF
- REGION III
- TECH ED
- PRPB:NRR
- NRR:DRSS:D
- OGCB:DORS
NAME
WGSnell
MMejac
LJCunningham
FJCongel
NECampbell
DATE
07/08/93
07/21/93
08/03/93
, 08/10/93
07/30/93 C:OGCB:DORS
D:DORS
GHMarcusS X
BKGrimesgX-
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07/
/93 Document Name:
IN-RADGR.PHY
- Electronic concurrence
- Projects has reviewed this information notice
Zion - Clyde Shiraki
Kewaunee -
Richard Laufer
Dresden -
Peter Erickson
- NMSS, Industrial, Medical
Nuclear Safety
Division Director
C.J. 44M4rtiasMU
08/10/93
IN 93-xx
August xx, 1993 (1) Heightened employee awareness of the potential hazards associated with
radiography through the use of station newsletters.
(2) Enhanced general employee training to ensure information describing the
controls and radiological hazards associated with radiography is related
to licensee employees.
(3) Emphasized the importance with regard to safety of obeying radiological
procedures, signs, and warnings to licensee employees.
This information notice requires no specific action or written response. If
you have any questions about the information in this notice, please contact
the technical contact listed below or the appropriate Office of Nuclear
Reactor Regulation project manager.
Brian K. Grimes, Director
Division of Operating Reactor Support
Office of Nuclear Reactor Regulation
Technical Contact:
Attachment:
List
William G. Snell, Region III
(708) 790-5513 of Recently Issued NRC Information Notices
- SEE PREVIOUS CONCURRENCE
OFF
- REGION III
- TECH ED
PRPB:NRR . ,
N RR:,D2S.D
OGCB:DORS
NAME
WGSnell
MMejac
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IJCunningham
X
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NECampbell
DATE
07/08/93
07/21/93 c6 d/3 /93 O /0o/93 O7/3o/93 j4
31 C:OGCB:DORS
D: DORS
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GHMarcus
BKGrimes
07/ /93
07/ /93 D cument Name:
IN-RADGR.PHY
E ectronic concurrence
5ttrojects has reviewed this information notice
Zion -
Clyde Shiraki
Kewaunee - Richard Laufer
Dresden - Peter Erickson
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IN 93-xx
July xx, 1993 (2) Enhanced general employee
controls and radiological
to licensee employees.
training to ensure information describing the
hazards associated with radiography is related
(3) Emphasized the importance with regard to safety of obeying radiological
procedures, signs, and warnings to licensee employees.
This information notice requires no specific action or written response. If
you have any questions about the information in this notice, please contact
the technical contact listed below or the appropriate Office of Nuclear
Reactor Regulation project manager.
Brian K. Grimes, Director
Division of Operating Reactor Support
Office of Nuclear Reactor Regulation
Technical Contact:
William G. Snell, Region III
(708) 790-5513 Attachment:
List of Recently Issued
NRC Information Notices
- SEE PREVIOUS CONCURRENCE
OFF
- REGION III
- TECH ED
PRPB:NRR
j
NRR:DRSS:D
OGCB:DORS
NAME
WGSnell
MMejac
j
LJCunningham
FJCongel
NECampbell
DATE
07/08/93
07/21/93
07/
/93
07/
/93
07/ /93
.,1 C:OGCB:DORS
D:DORS
GHMarcus
BKGrimes
07/ /93
07/
/93 Document Name:
IN-RADGR.PHY
- Electronic concurrence