ML050880096
| ML050880096 | |
| Person / Time | |
|---|---|
| Site: | Point Beach  |
| Issue date: | 04/07/2004 |
| From: | Nuclear Management Co |
| To: | Office of Nuclear Reactor Regulation |
| References | |
| FOIA/PA-2004-0282 ACE001666 | |
| Download: ML050880096 (2) | |
Text
I Nuclear Management Company Pagel of2 8 State Change History IC, ACE Initiate 0
by KREIL, JULIE Assign Work 4/7/2004 12:41:55 PM Owner
- SHERWOOD, GARY I
i' Reassign 0
by SHERWOOD, GARY Assign Work 4111/2004 2:42:28 PM Owner HAWKI.
LOYDE Assign 0
by HAWKI, LOYDE Conduct Work 411212004 5:08:29 AM Owner
- JENSEN, BILL Work Complete by JENSEN, BILL Review &
Approval 411612004 4:29:37 PM Owner
- HAWKI, LOYDE i..
8 Section 1 i QA/Nuclear Oversight?: N Activity Request Id:
ACE001666 v Licensing Review?:
N Activity Type:
Apparent Cause Evaluation Point Beach - Unit I Submit Date:
4/7/2004 12:41:55 PM Site/Unit:
Activity Requested:
Perform an Apparent Cause Evaluation of CAP055366 in accordance with NP 5.3.1. 30 day due date. Ensure you have finished the ACE CBT training. To access CBT, from Point Beach homepage - Work Groups - Training. Under the Point Beach Specific Training heading, click on Apparent Cause Evaluation.
s CATPR:
Initiator Department:
N PR Radiation Protection PB Initiator:
Responsible Group Code:
Activity Supervisor:
SHANNON,DAN 19 EPI Engineering Programs Inspection Services PB HAWKI, LOYDE 19 Responsible Department: Engineering Activity Performer:
El Section 2 JENSEN, BILL 9
Priority:
3 Due Date:
6/7/2004 Mode Change Restraint: (None)
Management Exception From Pl?: N NRC Commitment?:
@ Significance Level:
8 Section 3 N
@ NRC Commitment Date:
B Apparent Cause Evaluation: Event
Description:
While working In the Unit one containment building during Ul R28, a worker exceeded his electronic dosimeter dose alarm setpoint and received a dose alarm. The ED dose alarm level was set at 50 mrem and the worker received 51 mrem. The worker, along with two other workers, were working in containment on the wrong RWP. They were working on RWP 04-161, which is for work in the PAB, and set the ED dose alarm level at 50 mrem.
The correct RWP that they should have used is RWP 04-139, for their work in containment, which set the ED dose alarm at 80 mrem. The other two workers did not receive a dose alarm.
Extent of Condition Assessment:
All personnel affected with this event were Identified and coached.
Required Corrective Actions (Create actions if not complete):
After receiving the dose alarm, the individual left UI containment at the 26' elevation and reported to the RP station. The other two workers secured equipment and exited containment through the 66' elevation, also reporting to the RP station. RP management questioned the three individuals, initiated CAP 055366, and requested that NDE supervision and the Programs Engineering Supervisor, night shift, conduct a stand-down and brief all NDE technicians on the event, as well as conduct a Human Performance Event Investigation Tool synopsis of the event (iaw NP 1.1.10, 'Human Performance Program").
RP management restricted RCA access for the three individuals pending completion of these actions.The Programs Engineering Supervisor, night shift, and the LMT NDE Shift Lead, night shift, conducted the stand-down brief at approximately 2300. The Programs Engineering Supervisor, night shift, then interviewed the three individuals using the guidance of the Human Performance Event Investigation Tool.Lastly, after a final meeting between the three individuals, their supervisor, the Programs Engineering Supervisor, and RP General Supervisor, Radiation Support, the three individuals were re-authorized for RCA work at approximately 0045, 06 APR 2004.
4 /13 http://enwsO2/tmtrack/tmtrack.dll?IssuePage&Template=viewbody&recordid=593935&tab...
4/21/2004
Nuclear Management Company Page 2 of 2 Activity Completed:
Hot Buttons:
E3 Section 4 Apparent Cause Statement (Who, What, Why):
Three contract NDE technicians conducted radiation work in the Unit I containment during U 1 R28 under the RWP for PAB work instead of the RWP for Containment work, as required by NP 4.2.19, 'General Rules for Work in a Radiologically Controlled Area,"
Section 4.3, Radiation Work Permits (RWPs).A contract NDE technician then intentionally allowed his radiation dose to approach and exceed the (perceived, although wrong) dose limit for the RWP under which he was working in the Unit I containment during Ul R28, instead of exiting at an earlier opportunity, as required by NP 4.2.27, 'Personnel Exposure Monitoring Device Minimum Requirements and General Use." Step 3.7.1 states that the worker is to ensure that the exposure accumulation does not exceed that authorized by the RWP. In this case the RWP (although the wrong one) limit was 50 mrem (per entry).
Inattention to details (on NDE personnels part) and possibly making assumptions based on work performed at other sites appear to be the major factors in this incident.
4/16/2004 4:29:37 PM -JENSEN, BILL:
After receiving the dose alarm, the individual left UI containment at the 26' elevation and reported to the RP station. The other two workers secured equipment and exited containment through the 66' elevation, also reporting to the RP station. RP management questioned the three individuals, initiated CAP 055366, and requested that NDE supervision and the Programs Engineering Supervisor, night shift, conduct a stand-down and brief all NDE technicians on the event, as well as conduct a Human Performance Event Investigation Tool synopsis of the event (iaw NP 1.1.10, 'Human Performance Program").
RP management restricted RCA access for the three individuals pending completion of these actions.The Programs Engineering Supervisor, night shift, and the LMT NDE Shift Lead, night shift, conducted the stand-down brief at approximately 2300. The Programs Engineering Supervisor, night shift, then interviewed the three individuals using the guidance of the Human Performance Event Investigation Tool.Lastly, after a final meeting between the three individuals, their supervisor, the Programs Engineering Supervisor, and RP General Supervisor, Radiation Support, the three individuals were re-authorized for RCA work at approximately 0045, 06 APR 2004.
(None)
QA Supervisor:
@ ACE Event Description Grade:
- ACE Corrective Actions Grade:
(None)
Licensing Supervisor:
(None) l ACE Extent of Condition Grade: 0
@ ACE Apparent Cause Grade:
0 El Attachments and Parent/Child Links Subtask from CAP055366: Worker Received Electronic Dosimeter Dose Alarm by KREIL, JULIE (4/7/2004 12:41:56 PM)
I E Change History 4/12/2004 5:08:29 AM by HAWKI, LOYDE Last State Change Date Changed From *.
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Last State Changer Changed From *....... To......
4/16)2004 4:29:37 PM by JENSEN, BILL Last Modifier Changed From **....
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Apparent Cause Evaluation Changed From 'Event
Description:
Extent of Condition Assessment Required Corrective Actions (Create actions If not complete): Apparent Cause Statement (Who, What. Why):' To '[... ]While working in the Unit one containment building during U1 R28. a worker exceeded his electronic dosimeter dose alarm setpoint and received a dose alarm. The ED dose alarm level was set at 50 mrem and the worker received 51 mrem. Th[more diffs...I' Activity Completed Changed From " To '[Appended:] After receiving the dose alarm, the individual left U1 containment at the 26' elevation and reported to the RP station. The other two workers secured equipment and exited containment through the 66' elevation, also reporting to the RP st[...r State Changed From To......
Owner Changed From
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Last Modified Date Changed From *....... To *.......
http://enwsO2/tmtrack/tmtrack.dll?IssuePage&Template=viewbody&recordid=593935&tab...
4/21/2004