ML102460627
Text
QF-0433. Rev 2. (FG-PA-RCE-O I) RCE Report Template PageSlof81 Page 51 of81 xn.
XI]. Attachments
- Attachment I - Task Analysis
- Attachment 2 - Barrier Analysis
- Attachment 3 - Change Analysis
- or RMSP Procedures Attachment 4 - Evaluation of
- Attachment 5 - Event and Causal Factors Flow Chart
- Attachment 6 - Why Staircases NSP000035C
- Anachment 7 - Evaluation Attachment Evalualion of or Sarety Safety Culture lmpacts
- Attachment 8 - Glossary or of Terms
- Anachment Attachment 9 - Root Cause Charter Form retained in accordance with record retention schedule identified in FP-G-RM-O FP-G-RM-OI.
I.
QF-0433. Rev 2. (FG-PA-RCE-O (FG-PA-RCE-Ol)I) RCE Report Template Page 52 of 81 : J: Task Analysis (1) Steps in Procedure or (2) Walk through by (3) Questions I Conclusions Practice. (Enter step Analyst or trained about how task was I should number and short individual. (State how be performed.
description.) actual matches procedure.)
Evaluate the material RWSC is to consider RWSC provides little oversight of potential for small sources the packaging process, because
- 011.7 01 1.7,, step 6.9, of irradiated material prior items packaged correctly are not instruction instructionss for RWSC to packaging the material considered to be susceptible to or designee prior to (wrapping in plastic) changing dose rates. The RWSC packaging material cons ider the evaluation does not consider No mention of evaluation of the material a necessary part of RPlP 1122 of material in RPIP I 122 the RMSP.
RMSP.
- RPIP 1 122. hot particle I 122, (RCI) program Package the material Material is packaged for The accepted practice at PI is the controlling the spread of la~t 20 same as it has been for the last
- RPIP 1 I 122, hot particle contamination at PI. years, and PI has relied on a single si ngle program individual for more than 10 years.
Discrete particles need to (RC2) Put equipment in be restrained for shipment, polyethylene, and if it will be polyethylene.
both so the particle doesn't handled, put in Herculite.
move and so the equipment Industry standards dictate fixing containing the particle discrete particles and fixing loose doesn doesn't' t move. equipment so it does not move around during shipment.
RPIP 1122 is mute on RPlP packaging options and Discrete particles need to be methods for discrete restrained for shipment, shipment. both so particles. the particle doesn't move and so the equipment containing the RPIP RPlP does not implement particle doesn't move.
move .
effective methods to detect discrete particles that are Procedures do not describe fixed in materials. methods (RCt)
(RCI)
Form retained in accordance with record retention schedule identified in FP-G-RM-O FP-G-RM-OI. I.
QF-0433, QF-0433. Rev 2. 2, (FG-PA-RCE-O (FG-PA-RCE-Ol)I) RCE Report Repon Template Page 53 of81 : Task Analysis (1) Steps in Procedure or (2) Walk through by (3) Questions I Conclusions PractIce. (Enter step Practice. Analyst or trained about how task was I should number and short individual. (State how be performed.
description.) actual matches procedure.)
Place the material in the There must be a This evolution should be observed shipping container requirement that any RWSC. The use of by a qualified RWSC.
materials subject to discrete secondhand infomlalion infomlation does not
- 011.7 OIl.7., step 6.9.2 particle contamination is panicle ensure the material material is loaded ensures that the adequately maintained from correctly due to differing differin g mindsets materials are packaged facess of the container.
the face and experience. (RC2) in such a manner that This will ensure ensu re a robust under conditions program. This is a more Even though the container did not normally incident to nOffilally concrete task than ensuring have permanent shoring for the transportation, transponation . the disc rete you find all discrete lid, lid. industry best practice is to hift materials will not shift particles.
panicles. ensure that radioactive radioacti ve material is within the package. packaged such that it does not come in contact with any interior faces of the shipping container.
Survey the material to be Each is a SHALL The requirements to eva evaluate luate the shipped statement. material s.
s, observe the packaging.
packaging, and observe the loading.
loading, all must
- o I 1.7, steps 6.10.5.
011.7. 6.1 0.5, be SHALL statements to have a 6.10.6, and 6.10.7 6.10.6. There was no discudiscussion sion of robust RMSP. (RCI) ensure that material to packaging of equipment eq uipment so be shipped is surveyed.
surveyed . the equipment does not All the appropriate surveys were move. completed, the results of some
- RPlP RPIP 1319 (loading were questioned and some results LSNSea-Iand boxes)
LSAlSea-land were re-surveyed. All of these are requires mmerials materials to be appropriate actions. It is loaded so that nothing impossible to survey shifted shifts. materials.
Complete administrative Adequate but not very well Shipping paperwork was paperwork laid out on these processed correctly with no requirements. deficiency..
identified deficiency
- 011.7 DIU Form FOffil retained in accordance with record retention schedule identified in FP-G-RM-O FP-G-RM-Ol. I.
QF-0433, Rev 2, QF-0433. 2. (FG-PA-RCE-Ol)
(FG-PA-RCE-Ol ) RCE Repon Report Template Page 54 of of8181 : Barrier Aoalysis Definition - Barriers are devices emplo}ed employed to protect and enhance tthe he safety and performan performance ce of the plant.
plant-Energy I Hazard Barrier Assessment Target Delection Detection of discrete Qualjfied Qualified A gross survey of the equjpment equipment was completed when the e valuation of the Detailed evaluation particles on partkles Workers sipper was first fust lifted from the spent fuel pool after the material equipment. completion of the tbe used fuel test for defects. This survey was completed by qualified RP technkians technicians covering the spent fuel pool job. This survey was completed for the pUr]JOse of contamination control and determining purpose determiillng the decon method. Based on the gross survey hit was decided that decontamination of the canister would take place underwater.
As the equipment was decontanUnated, decontaminated. a detailed survey was completed by qualified in house and contract RP pUr]JOse of this survey was for exposure technicians. The purpose control.
indjviduals involved in the surveying of the material The individuals matenal were qualified to do the job coverage task according to reqttirements in place at the time.
station requirements tjme.
No effective barrier existed to confirm Subpan H confLrm Subpart qualifications for individuals involved in shipping related activities.
This barrier was determined Thjs determjned to be in place, although no specific training and qualification requirements for radjoactive srupments could be jdentified.
radioactive shipments identified. (CC2)
Form retained in accordance with record retention schedule identified in FP-G-RM-Ol FP-G-RM-O I..
QF-0433, QF-D433. Rev 2,2. (FG-PA-RCE-OI)
(FG-PA-RCE-Ol) RCE Report Repon Template of 81 Page 55 of81 : Barrier Analysis Defmition Definition - Barriers are devices emplo,ed employed to protect and enhance the safety and performance of the plant.
Energy I Hazard Barrier Assessment Target Detection of discrete anning I Job PI.
Planning Noo specific task was included in the work plan for the Risk significant rad particles on Preparation radiological evaluation of the equipment. shipping evolutions are equipment. appropriatel y planned via The RP technicians were briefed on the removal of the the work planning process equipment from the refuel pool to include a survey for and have adequate ALARA exposure control. The briefing did not include specific planning.
direction for surveying for shipment.
The task was not planned as an integral part of the work planning process. (RC2)
This barrier was determined to be missing. This was a missed opportunity to have the task clearly defmed and scheduled.
Form retained in accordance with record retention schedule identified in FP-G-RM-Ol.
QF-0433. Rev 2. (FG-PA-RCE-OI ) RCE Report Template of88 1 Page 56 of : Barrier Analysis Definition - Barriers are devices emplo}ed Defmition employed to protect and enhance the safety and performance of the pla nt.
plant_
Energy I1 Hazard Barrier Assessment Target Procedure RPIP I1122122 - Hot Particle Program does not Detection of discrete Procedures 1I provide adequate guidance. The procedure does not include particles on Work an applicability statement outlining when the procedure is to equipment Instructions be used. There is no indication that the procedure was to be included in the task of surveying the equipment on 10/23/08. A second example is that step 7.1 requires either a direct frisk of the material to be removed or a large area (Masslin) survey. Large area surveys will not detect particles embedded in the material (such as in small crevasses or plastic coatings etc.). These particles can become dislodged after removal from the particle area.
Direct surveying of the material should be the fInal final determining factor for removal of material from an area.
Additionally direct survey of the material must be done if the material is to be shipped offsite in order to ensure that any potential small discrete source of radiation is identifIed.
identified.
Another example is the guidance in step 7.3.2 is weak in that it does not direct the contact of shipping personnel for evaluation of appropriate surveying methods and packaging material to ensure their suitability for shipping.
shipping.
Thiss barrier was determined to be in place but ineffecti Thi ineffective.
ve.
Fonn Form retained in accordance with record retention schedule identified in FP-G-RM-Ol.
identifIed in FP-G-RM-O 1.
QF-0433, Rev 2, (FG-PA-RCE-OI (FG-PA-RCE-OI)) RCE Report Template Page 57 of81 of8 l : Barrier Analysis Dermition Defmition - Barriers are devices employed emploJ ed to protect and enhance the safety and performa performancence of the plant.
E nergy I Hazard Energy Barrier Barr ier Assessment Target Procedure DII.7, DI!.7, Radioactive Materials - Shipment - LSA Detection of discrete Procedures I I SCO I LTD Qty to a Licensed Facility, step 6.9. 1, state:
states:
particles on Work equipment Instructions "6.9 Prior to packaging, the RWSC or designee should:
6.9.1 Consider the potential for small sources of irradiated material to inadvertently remain within the internals of the equipment. The higher radiation levels of the irradiated materials may be masked by the intrinsic shielding of the equipment."
The procedure is inadequate in its guidance on packaging.
(RCI)
PI shipping personnel are Detection of discrete Verification I PI shipping personnel visited the fuel floor during the anyy present to evaluate an particles on Validation equipment evaluation step in the shipping process. evolutions that are risk equipment significant.
This barrier was determined to be weak. Procedure guidance does not require verification and validation of the evaluation process. Though the shipper is qualified to thiss task has been typicaUy conduct the surveys, thi typically delegated to RP technicians. (CC2)
The supervisor provides Detection of discrete Supervisor The supervisor was monitoring multiple tasks during the meaningful oversight for particles on Oversight course of the outage. The current and previous supervisors tasks that represent equipment are not qualified in the area of shipping. (CC2) significant risk Form retained in accordance with record retention schedule identified in FP-G-RM-O I.
QF-0433, Rev 2, (FG-PA-RCE-OI)
(FG-PA-RCE-Ol) RCE Report Template Page 58 of 81 of81 : Barrier Analysis Definition - Barriers are devices employed to protect and enhance the safety and performance of tthe he plant.
Energy I Hazard Barrier Assessment Target All discrete particles that Detection of discrete Worker Practices The personnel assigned to the initial evaluation of the fuel are of dose consequence for particles on sipping equipment completed an adequate assessment of the the planned tasks are equipment equipment for hot particles. located and adequate radiological controls put in place to keep dose ALARA.
Form retained in accordance with record retention schedule identified in FP-G-RM-O 1.
Fonn I.
- Change Analysis Problem Statement - Prairie Island failed to ensure equipment was adequately packaged to prevent excessive radiation levels on the exterior of a container shipped from Prairie Island to Waltz Mill.
Previous Condition Current Condition Change I Difference Impact or Assessment Sipper design - lid is integral lid Lid detaches from sipper Position of lid is no longer tied Shipping container did not change for to sipper sipper design canister. to can ister canister change to equipment Sipper lid - lid is used for lid Lid used for either canister More efficient overall site fuel New design puts lid in path of fuel single canister only.
only. sipping evolution detritus Sipper Canist Canisterer - single Two barrels Makes sipping Sipping evolution Requires different lid design.
barrel quicker, can load one while testing another bundle Decontamination The lid was decontaminated Past methods had special No noted impacts.
methodology methodology - There was a while suspended over the tools to spray down inside of special tool to 'hose off' the pool sipper canister.
intemals of the sipper; internals sipper; spray The canisters and remaining hoses were used for the rest sipper equipment was of the equipment.
decontaminated underwater with a high pressure spray hose.
Shipping container- New lid design (detached) Equipment that went in the Error likely situation - equipment design of the sipper was with was not accommodated in SFP was no longer exposed to discrete particles not kept integral lid, permanent the container. maintained from the face of from faces of box.
box. Additional shoring was used to maintain box, by design the box, container loading activities were distance from equipment to needed.
faces of container Container loading - no Some items (the lid) were No longer maintain a specific Error likely situation - Additional items immersed in SFP were able to be placed close to location for all items packaging material required to able to be close (by design) the sides of the container immersed in SFP (except for maintain lid away from from sides of the to the sides of the container umbilical) container.
Fonn retained in accordance with record retention schedule identified in FP-G-RM-O lI..
Form
- Change Analysis Problem Statement - Prairie Island failed to ensure equipment was adequately packaged to prevent excessive radiation levels on the exterior of a container shipped from Prairie Island to Waltz Mill.
Previous Condition Current Condition Change I Difference Impact or Assessment Wrapping methodology - Wrapped to PI standards None. Changes needed to package shipped wrapped to PI standards which control contamination materials subject to discrete particles.
which control contamination spread. Wrapped Need to fix equipment andlor discrete spread. Packaged as part of separately from sip per. particles to prevent movement during sipper, not separate. shipment.
Condition of fuel sipping Material left PI with Immersed in SFP, subjected Change in equipment radiological equipment - Material came significant radiological to discrete particles status changed the packaging and into PI without any hazards reqUirements, but changes shipping reqUirements, radiological controls. were not assessed properly.
Form retained in accordance with record retention schedule identified in FP-G-RM-O I.
l.
- Evaluation of Procedure of8 1 Page 61 of81 Evaluation of procedure DU.7: Dll.7: Radioactive materials shipment - LSAISCOfLTD LSAJSCOILTD QTY to a licensed facility.
Tbis This evaluation is lim.iled limited to sections sect ions of procedure 011.7 D 11 .7 which have specific bearing on RCE 01157726 01 [57726 Radioactive Material Shipment Exceeded DOT Limits.
I. Step 6.9, 6.9.1 and 6.9.2 should be part of the radioactive material packaging procedure (RPIP- (RPlP-1319).
13 19). See evaluation eval uation below.
- 2. Step 6.9.1 directs the Radioactive Materia.l Material Shipping Coordinator (RWSC) or designee to potential impact of small consider the potentia.l mall sources of irradiated material (discrete particles) to remain within the internals of the equipment. This requirement needs to have guidance added to enable the RWSC to perform an effective evaluation eva luation to ensure that any potential sources have been identified, and measures taken to prevent them from migrating to a position where they could cou ld have an effect on shipmen shipmentt parameters. The consequences part pan of the steps shou should ld be convened converted to a caution statement placed above the tbe action step.
- 3. Step 6.9.2 directs the RWSC or designee to ensure that the material s be packaged in such a manner that under conditions normally inc ident to transportation incident transponation the materials will not shift within the package. Add guidance to ensure that an effective evaluation of the methodes) used to prevent movement is adequate. The consequences part pan of the steps should be convened converted to a caution statement placed above the action step.
- 4. Consider adding a step in the checklist here that the material was packaged in accordance with RPIP-1319 .
Evaluation of procedure RPIP 1319: Loading LSA Boxes/Sea-land Containers.
should be "Packaging of Radioactive Material for Shipment" and expanded I. The title sbould ex panded be a comprehensive procedure that controls the packaging of all radioactive materials shipped offsite. The one exception would be itemsitem s packaged in accordance with an engineering package such as steam generators, reactor head etc.
- 2. A complete rewrite of the procedure needs to be accomplished. Currently the procedure is designed to give guidance for segregating and packaging waste material for shipment. There is no guidance outlining methods to be used for securing material such that it will not move during transport.
transpon.
- 3. There is no guidance outlining methods to be used for securing material such that it will not transport. The only mention of securing material is in the precautions and move during transpon.
limitations with no guidance given.
particles are not mentioned In
- 4. Discrete panicles in the procedure.
Form retained in accordance with record retention schedule identified in FP-G-RM FP-G-RM-OI-OI..
Auachment 5 - Event and Causal Factor Chart Attachment Chan Page Page 62 of81
',Ol,-2mB (02O)j 1r 09i12m8 (O14) 09i12i08 (014) (020) 09/16108 (026) 10l23I08,1100(022) 10/231081100 (022) :
09/19108 (028) 1011-22108 (026)
(066) 313108 (066) I Westinghouse New WestInghouse P1anning PlaMing SFP area being SFP area set-bHIg set*
t'8C*Y8d as_ t- _ loosed Fuel SIllPO' 2R25 refueling - . , I UsedUsed fuel hJeI bundles buncles OE26644 receNed 0E26M4
"",m,,".,., leased Fuel Sippel" f--o fuel_ If----o oompIete for compH!te lor up for up roc evolution eYOIutIon of 01 I ~8mYeSat outage
-begons beglrlS were
- . . tested lor IeSIed for
.-....t.oon only' oro; eqlJIprTleflt amves at fueI ..ppmg 1akJng~
takmg sipping
~
defects by Slppu"Ig PI IW36n53
'N0367253
,. ----' _ _--'I I defects by " -
equipment eqwpment out out c:I d pool pool
.f,, Forwanled as bneftngma_
os tAl
.,"-d-.
boefing material Shopping not
_speafic:aIy add<lOSSed
_ressed I No"..,.,....
NoptOOOSS ., 'NO as (n WO FP-RP*
11$ per FP-RP-
,Ch8.ngeI Change5 made mIde as JPP...()l JPP-01 I a resort of
RP does not eIIocb'"'Y W'ICiOrJl'CX'iIte nol effectJvery """'J>O<lIte industJy
_SOy experwa expenence 10 to mprove ttr'IpI"OVe the RMSP RMSP RC2 L JI~0123108 10l23I08 (017, (017. 023) 10l23I08 10/23108 (017 (017. 023)
To
_ed 1D123108 10123/08 (017 023) 023) :
The pOonbes the lite has glYen 10 RMSP do not align With the JX,rtenbal Stpper (017. 023) equipment is Slpper equipment is
- Ipper Sipper lid lid Is is removed removed Sippef cab6es are SIppel" lid and cables P2 suwyed surveyed underWater underwater i from from the Slpper and the Sipper and removed from water and acNene~ fOr jOb coverag<V derontalTllnated decontamonated ........yed lor JOb """""'9&
The Lidlid swveyed
...wyed I 30 em 11m. readlOgs DC 130 readlllgS 120 ISO I 1Q mRlhr 150 110 mRnY (017)
LAS of lid and ca~
lAS detected no loose Cletected k)ose discrete
_(023)
Techruaans were not IJamed in shipping related adMIJes Event and Causal Factor Chart Key Add~ (~~cause) f IntonnatlOn Addi1>ONIi ( ConInbubng Cause) ~ ------ raining CC2 and qualification shippers' OoIe1Tme OoteITome DodO I DodO f ,~ .. ......
lnappiopiate
)")
AdJon AdIon
~
~
k1famatJcn
~
o *
(CC) Tenn""""",)
' Tern""",,",,
E_
rtWW'Ig qualif1callOn for tad and RP tectmK:ians tec:hnoaans who peffofm rad stvppers:
perform--"
adMtJes do not meet IndUStry related acbvrtJes shipping IndustJy standa<ds SIa>1datds
[ TIIl"Iehne E.....ant Tmehne Event (tA)
(IA)
.--J
( Cause Root Couse
) ------....-
'---./
F.... Barner Failed 8ame< (RC)
Form Fonn retained in accordance with record retention schedule identified in FP-G-RM-O I.
- Event and Causal Factor Chart -'P-=;~ge Page 63 ofof81
,t r -_ _- 81
_""-_ _caru. .
_ 10l23I08,1800 (017 023)
~-----,
rl'-"012
- -(-0 )'
10/23108 (027) I 10124108 1012. (023) 108 (023) I-. 10J24108 (023) 10124108 1012.108 (014, lQf2<41D8 (01., 023) 10124108 (014)(01.)
10123108 (017. 023) EqutpmeOt Equ!pment toaded bided into I The rue! a.pper canlSlIn SIppIng canister Westtoghouse
'Alestinghouse -a. The shipping c:ontalfler container is Transport whIde vetlide and put off 10 the &de Il/"8 su..-..yed for job c::cwrage upon removal wu wrapped in wuWT-wedin Hercurde Hera.(",
aM ~
d'Ie
.,Westing-
- shippwIg container c:ontaJnef labcntrs do5e ahlj)pItIg container I shJppIIlg con~
- SllI'\Oeyed wndof RP surveyed by vendor techniOan technician IS
"""'"Y os
-pool peBOnnei
"""""neI """"""""
~ in 1I--
UmbM::al cables era a leplrate Wf1Ip (017. 027) lAtw'IQ brdt cables are pIac::<<Ioni:JpdIMldand r
~
ean.....u........ at OC J 30 an. Rudlngs.
120 I 20 mRhlr (017)
Qb Slpper In the bottDm in botDn 01 F81 F8 .
SIppel' lid and cables are placed d the container no additloNl c:ontall'lef wlth additional support or sep8fl1bon c:onsJdered separlltlon F82 c:onsdered (03, 027)
(03.
F8 2 t--The The talepole on teiepole readlO5iJ was 170 mRItv 01'1 bottom
'c.ncontaner container reading contact mRn\t contad boHom of shipping (01.)_
ContaIner tagged with Highest reading on transport vehicle Is 80 mRIIv 80 mRlhr IS 40% d DOT shipping flfmts (MN mrlhr reading 170 nvlhr w _ (03) DeplalH....
No specific survey was.
5UfYe)' was rooT mR/hf limit IS 200 mRlhr DOT limillS notificatiOf'l not reqUired) for shipping ordered 101 vllpping (016) y UU U:J
_1ueI_ ""' ...
..-... IAl IA*
~fuelSCIt*
Faied a.mer FaJed S.mer cabtes cables to 10 prIM!M prevent J
.fhifmg
.fhilbng lAW IAWOl1 Z 011 ,.Z step69 stap 69 '
IA2 tAl RMSC did not verty
~MSC vedy that the
--I
~~_I
~
5UM!Ij
_Ie""
ShIPPIng pac:Ug.ng was survey or packagWlg
((014) 01.)
CC2 m~
,........:.l....... ;;.-.;
u ::...........
(
( RCl ~C2 ))
C§D Fonn retained in accordance with record retention schedule identified in FP-G-RM-Ol. FP-G-RM-OJ.
Anachment - Event and Causal Factor Chart
""'_. U 1~~5108 . .11CJ3M)8 J
.f-> -J Page 64 of I
of81 81 1(125108 r lCJ25.1Oa (0 1<4 ,
101.
lCI3OJ08~12"5 lCJ3OI()8-.124S ,De: coe: 1(I30I08 IC/3OI06 1305 (023;
,023:
C/29108 090C ID14Dl!t' 1C/29108"'1021]
1(129108-1020101" 101 '; 065f 102.'
102-4' Ptaire 1$Iand shippen lC129I08 090( 1014 01~~.; The tnJck truck is reieased, is -'sod lCIJOJ08 065E , Initil!l.,1ftMVatwattzMJI tniba!
- t.UIY8)' at wattz Mil Trailer moved to Weltz Waltz I The IrIIkw
- dIscuu contKI dose ratef ........... n'IO\Ied., the ... -.. Contalner Containef 1'I:~&UI'Ve)'ec
~surveyec - f---.. The PI ., go II:)
., 1Nattz VYattz -II1TrudI:
Trudt amves at Waltz -.. determenes
-....... 80
' -1 mRhu Mil RCA and OOtlanef oon\lllner l
1--' mcM!Id., ..
/'I. from PlIO from 80 mRnl' from II'\lbIII survey due tc new
_ reading readlOQ W&!Waf 15C IS( mRltv Mil F~ity Mil "",heat contact hlghest oomact reacmg reading ramoved IrUer and removed from tr.iler resUtI being dose to DOl
......... R.".
"'"""" RC'O Mil Fdity '" boaom at on bockIm traJer 01 traier swveyo<
surveyec:
+m4 and decide to 11!......-ve)'
No .c8on reqUll'lld by b...._ .
Sheppers ~ to usem
~-
mRnv OC mR/tv OC reachng use 17C
~use reading because
~ings suniar R;;dilgl taken for taken S/miar toto readings readings Yf!hide survey ror vehide survey pt'OC*1ure 101* It was It fTIOI'lI oonset'Y8M was ITIOI'e conservative before ~ left P before trudt left P 101-COl
- 0'111 014; ,",::,"",:,," ,
( Re. ) ~
L--- n; .....
The in,,* s.urvey swv ey_
perfonnec
(( RC 2 )
RC' ) at W8Itz w.Itz Mill did not meet mee1 ..
cntena c::ntM\8 for 173 <<11" fof 17:! .... , I' :. cA of 4SCFR 49CFR and did not mimIC rnirlUc the transport transpon survey peIfofmed at PI priof performed pOor to the' the L- traierlea~
trailer Iea~
I 1(131108 C10" Vendor measured Vend<<
I 2000 mRlhrhDI l
D'.
mRlhr hot spot
\ on bottom surface of
&pOI 01 I 1[131108 102' 1(I3M'. '0' Wesmghouse notifies PI Wesbnghouse notif)es exceedance of possible exceedaoce 01 DOT L II ...
1 ,1'/03108 0103108-1"'4108(03:
- " 11111108(03:
M. for v.ttz loti
'w'\Wtz tnMIIlD persoMel travellD PI personnel pretunnar, for pretim.na.r) r ENe regwation for con regu1atJOn contact . . dose InYeSbga1X::w InYeStJgalior stllPPAg oontamet shipping oontalt1ef
~
PI Plant Mal'\8gef Manager fssuetIssuef WOI'k order on RAIl Slop wcwk atop
~I01
~I014 '(.
Rad_",
R&d shlPP'~
procedures quaranbneC qullranbnec:
Form retained in accordance with record retention schedule identified in FP-G-RM-Ol. FP-G-RM-O 1.
Allachlllcnt 6 Why StaircJsc Analysis Page 65 ofor S81 I
Why 1.0 Rad shipping container from PI exceeded 49CFR173.44 49CFRl 73.4411 limits for contact radiation levels over 200 mrem/hr (01 ., 016) mremihr Why 1.1 1.1 Contact reading on bottom boHom of box @ Waltz Mill Westinghouse facility read 2000 mRihrmRlhr (01 )
Why 1.1.1 A discrete particle was close to bottom of container (03)
Why A The discrete particle shifted during transport or unloading (01 5, 01)
Why a. Was not packaged to prevent shifting lAW 011.7 step 6.9.2 (011)
~ IA1 - See WS2 IAl Why B A discrete particle was contained In in the shipment Why a. Equipment was immersed in SFP Why b. Particle was not removed prior to packaging
~ Particle was not detected during job coverage survey to remove sipper from SFP (017)
Why cc.. See WS3 Why 2.0 Workers did not package the fuel sipper to prevent shifting (cables not fixed to lid, lid not separated from bottom of the box) lAW 011 .7 (IA1).
Why 2.1 No perceived need to package for discrete particles Why 2.1.1 No survey indicated significant discrete particles (017)
Why A Refer to WS3 Why 2.1.2 PI relied on vendor to package the package (014)
Why A The vendor personnel were experienced and had been used for this task In the past in Ihe Why B It was the vendor's equipment Why C Vendor personnel were the most experienced persons available to perform job (014)
Why a. No in-house qualification for shipping*specific shipping-specific tasks (CC)
Why 2.1.3 Step 6.9.2 of 011 .7 is not prescriptive Why A See RC1 Why B The site relies on a single individual to control RMSP evolutions See RC2 Forn1 Form retained in accordance with record retention schedule identified in FP-G* FP-G-RM-Ol.
RM -OI.
AII;II:hment 6 Why St,me I,~ "'naly,is Page 66 or81 of 81 Why 3.0 Particle was not detected during Job job coverage survey for removing and wrapping the fuel sipper from the spent fuel pool Why 3.1 Particle was difficult to detect with job coverage survey (04, OS, 05, 017,diagram)
Why 3.1.1 Oose rates measured with RO-2 RO*2 at 30 cm were 20-30 20*30 mA/hr mRlhr (i.e. not significant to general area dose rates) (023, diagram)
Why 3.1.2 Large Area Smears of equipment and cables detected no particles (023, 017)
Why 3.1.3 All discrete particles found in area were of low dose concern (017, (017, 023)
Why 3.2 Survey conducted for job coverage per RPIP 1135 versus an equipment survey for rad shipment evaluation lAW 011.7 (011,(011 , 025)
Why 3.2.1 Person doing job coverage survey was not required to be familiar with 011 .7 and 011.7 was not referenced in work documentation (see WS4)
Why A A Person was following RPIP 1122* 1122 - Hot Particle Program (029)
Why a. RPIP RPI P 1122 Is is not prescriptive with respect to rad shipping concerns (RC1)
Why BRad shipper brief was only about decontamination target levels. levels, not discrete particles (014,023).
(014, 023).
Why C RMSP is outside work management program Why a. See WS4 Why 0 Personnel completing surveys and packaging equipment are not qualified RWSC. RWSC.
Why a. No training program exists to specifically describe shipping tasks
>> The training and qualification for rad shippers and RP personnel who perform
}> perlorm shipping related activities does not meet Industry industry standards (CC2, RC2)
Why 3.2.2 RWSC did not verify surveyor packaging was adequate for shipping (1A2) (013)
Why A 011.7, section 6.9 did not require additional, shipping* specific, surveys (013) shipping-specific, Why a. RC1 Why B RWSC relied on RPSs to perform perlorm rad shipping evolutions (see WS2)
Why C RWSC was focused on documentation and transport survey (014)
Why a. B. Believed the job coverage survey was adequate to address transport requirements of 011.7 step 6.9.
>> Oid not adequately Incorporate
}> incorporate industry OE related to similar rad shipment Issues issues (OE23408, OE26644) (CC1)
>>}> Site relied on single individual to conduct rad shipments Instead of strong process guidance. (RC1)
Why DOose rates seen during the job coverage survey were close to decon targets (reduction from 40000 mRlhrto mRlhr to 120 mRlhr) (011, 014,014 , 017)
Why E E Oose rates were not out of line with worker and RWSC expectations for SFP equipment (014)
Why a. B. Oose rates were close to the target dose rates provided to RPS (011 (011))
Why b. No other surveys conducted prior to packaging for shipment
> 0117, 0 11.7, step 6.9 did not require additional, shipping*specific, shipping-specific, surveys (0 13, RC1)
(013.
Form retained in accordance with record retention schedule identified in FP* G RM-Ol.
FP-G-RM -Ol.
Attachment Auachl11cnt 6h - Why Swirca,c Staircase Analysis Page 67 of 81 81 Comparison of fuel sipping lid general area and discrete particle dose rates dose rate distance line 1 meter away from sipping
, =
lid 7 to 10 mRthr =
.... '. , ambient work area dose rates
, 3 to 20 mRthr
- ......';,;,'........-__ 30 em
- a. cm from particle =
,'. , 20 to 30 mRlhr
' ." , General area at 30 em from fuel
". ,sipping lid lid"" 50 mRlhr
-...._..* = dose rate Instrument reading
- = discrete radioactive particle (not drawn to scale; particle Is microscopic) .
scale; actual
= ambient work area dose rates (at (all1 meter)
= job Job coverage dose rates by lid (at 30 cm)
(a130 t1!JIi}) = fuel slpper lid lifting cables (approx 30 feet) feel)
Why 4.0 Shjpping Shipping not specifically addressed in WO 367253 as requi required FP-RP-JPP-Ol.
red by FP-RP-JPP-O I, step 5.5 (IA3 ).
(IA3).
Why 4.1 Job waswa~ not Passport approved until the begi beginning outage. (026) nning of the 2R25 refueling outage.
Why 4.1 .1 WO was moved up from post-outage to beginning of outage (023, 4.1.1 (023. 026)
Why A A Utilize available availab le contractor resources.
resources. (014)
Why 4.2 RP Planners consider sipping sippi ng and shipping shippi ng toLO be part of refueling Why 4.2.1 Fuel Fuel sipping has always been pan part of refueling evolution Wh y 4.2.2 Work Order process does not consider RMSP a discrete task Why Why A A RMSP is outside work management program Why a.a. RC I ,md and RC2 Form retained in accordance with record retention schedule identified in FP-G-RM-O FP-G-RM-OII..
- Safety Culture Impact Page 68 of 81 of81 Safety Culture Description of Component Impact Description of Impact: CAP ref:
Component:
Human Performance (HU)
HU - (H.1)
(H.l) Decision-Making. - Decisions demonstrate that nuclear safety is Impact The site did not have a CAPR Decision Spec~ically (as applicable):
an overriding priority. Specifically IRI 00 Yes method for determining 01157726-06 Making
- The site makes safety-significant or risk-significant 0 No risk significance sign~icance of decisions using a systematic process, especially when events related to rad CAPR faced with uncertain or unexpected plant conditions, to shipping. 01157726-07 01157726*07 ensure safety is maintained. This includes formally Assumptions regarding defining the authority and roles for decisions affecting the adequacy of the rad CA nuclear safety, communicating these roles to applicable survey and container 01157726-25 personnel, and implementing these roles and authorities as packing technique were designed and obtaining interdisciplinary input and reviews not conservative. When on safety-significant or risk-significant decisions. the original equipment
- The licensee uses conservative assumptions in decision survey indicated 120 making and adopts a requirement to demonstrate that the mremlhr, mrem/hr, and the proposed action is safe in order to proceed rather than a subsequent container requirement to demonstrate that it is unsafe in order to survey indicated 170 disapprove the action. The licensee conducts effectiveness mremlhr.
mrem/hr, the opportunity reviews of safety-significant decisions to verify the validity of the to validate the integrity of undertying underlying assumptions, identify possible unintended that packaging was consequences, and determine how to improve future decisions. missed. (CC1)
- The licensee communicates decisions and the basis for decisions deciSions to personnel who have a need to know the information in order to perform work safely and in a timely manner. H.1 (c)
Form Fonn retained in accordance with record retention schedule identified in FP-G-RM-Ol.
Auacbmem - Safety Culture lmpact Impact Page 69 of 81 Safety Culture Description of Component Impact Description of Impact: CAP ref: I, Component:
HU - (H.2) Resources - The licensee ensures that personnel, equipment, Impact Procedures are not CAPR Resources procedures, and other resources are available and adequate to 00 Yes adequate. (CC3) 01157726-07 ensure nuclear safety. Specifically, those necessary for: 0 No
- Maintaining long term plant safety by maintenance of design Training is required for CA margins, minimization of long-standing equipment issues, RPTs performing RMSP 01157726-20 minimizing preventative maintenance deferrals, and ensuring work. A qualification maintenance and engineering backlogs are low enough to program will be CAPR support safety. implemented. (CC2) 01157726-13
- Sufficient qualified personnel are trained and available to maintain work hours within working hour's guidelines. CA
- Complete, accurate and up-to-date design documentation, 01157726-22 procedures, and work packages, and correct labeling of components.
- Adequate and available facilities and equipment, including physical improvements, simulator fidelity and emergency facilities and equipment.
Form retained in accordance with record retentinn retention schedule identified in FP-G-RM-OI.
FP-G-RM-Ol.
- Safety Culture Impact Anachment Page 70 of of 8 811 Safety Culture Description of Component Impact Description of Impact: CAP ref:
Component:
HU - (H.3) Work Control - The licensee plans and coordinates work Impact RMSP activities are CAPR Work Control activities, consistent with nuclear safety. Specifically (as [RJ Yes
!Rl usually completed 01157266*06 01157266-06 applicable): 0 No outside of the work 0 The licensee appropriately plans work activities by management process. CAPR incorporating: Shipping tasks and the 0115n26-07 01 157726-07
- risk insights risks associated with
- job site conditions, including environmental conditions, shipping are frequently CAPR which may impact human performance; plant not addressed in work 0115n26-13 011 57726-13 structures, systems, and components; human-system packages. RP interface; or radiological safety technicians providing job CA
- The need for planned contingencies, compensatory actions, coverage for 0115n26-22 011 57726-22 and abort criteria. decontamination are not aware of rad waste CA 0 The licensee appropriately coordinates work activities by shipping requirements Shipping 0115n26-24 01157726-24 incorporating actions to address: with respect to discrete
- The impact of changes to the work scope or activity on particie particle issues.
the t he plant and human performance. (CC3)
- The impact of the work on different job activities, the need for work groups to maintain interfaces with ollsite offsite organizations, and communicate, coordinate, and cooperate with each other during activities in which interdepartmental coordination is necessary to assure plant and human performance.
- The need to keep personnel apprised of work status, the operational impact of work activities, and plant conditions affect work activities that may allect
- Long-term long-term equipment reliability by limiting temporary modifications, operator work-arounds, work-arounds, safety systems unavailability, and reliance on manual actions. Maintenance scheduling is more preventive than reactive.
Form retained in accordance with record retention reten tion schedule identified in FP-G-RM-Ol.
- Safety Culture Impact Page 7711 of 81 Safety Culture Description of Component Descnption Impact Description of CAP ref:
Component: Impact:
HU - (H.4) Work Practices - Personnel work practices support human Impact Inadequate CAPR Work performance. Specifically (as applicable): 00 IRI Yes oversight 1157726-07 Practices
- The licensee communicates human error prevention 0 No (RMSP and ttechniques, echniques, such as holding pre-job briefings, self and peer supervisors) CA checking, and proper documentation of activities.
activities. These during 01157726-01 157726-techniques are used commensurate with the risk of the packaging, 14 assigned task, such that work activities are performed safely. surveying Personnel are fit for duty. In addition, personnel do not proceed in and crating the face of uncertainty or unexpected circumstances. evolutions.
- The licensee defines and effectively communicates expectations Some of the procedures..
regarding procedural compliance. Personnel follow procedures behaviors
- The licensee ensures supervisory and management oversight that of work activities, including contractors, such that nuclear contributed safety is supported. to this event do not support human performance
'(CCl)
(CC1)
Fonn retained in accordance with record retention schedule identified identi fied in FP-G-FP-G-RM-Ol.
RM-Ol.
- Safety Culture Impact Page 72 of 81 Problem Identification and Resolution (PI&R)
Safety Culture Description of Component Impact Description of CAP ref:
Component: Impact:
PI&R -(P.1)
- (P.1) Corrective Action Program*
Program - The licensee ensures that issues Impact None None Corrective potentially impacting nuclear safety are promptly identified, fully 0 Yes DYes Action evaluated, and that actions are taken to address safety issues in a 1&1
[8J No Program timely manner, commensurate with their significance. Specifically (as applicable):
- The licensee implements a corrective action actio n program with wit h a low threshold for identifying issues. The licensee identifies such accurately, and in a timely manner issues completely, accurately, commensurate with their safety significance.
- The licensee periodically trends and assesses information from the CAP and other assessments in the aggregate to identify programmatic and Issue common cause problems. The licensee communicates the results of the trending to applicable personnel.
- The licensee thoroughly evaluates problems such that the resolutions address causes and extent of conditions, as necessary.
This includes properly classifying, classifying, prioritizing, and evaluating for operability and reportability conditions adverse to quality. This also includes, for Significant significant problems, conducting effectiveness reviews of corrective actions to ensure that the problems are resolved.
- The licensee takes appropriate corrective actions to address safety issues and adverse trends in a timely manner, commensurate with complexity.
their safety significance and complexity.
- If an alternative process (i.e.,
(i. e., a process for raising concerns that is an alternate to the licensee's corrective action program or line management) for raising safety concerns exists, then it results in appropriate and timely resolutions of identified problems.
Form retained in accordance with record retention schedule identified in FP-G-RM-Ol.
- Safety Culture Impact Page 73 of81 Safety Culture Description of Component Impact Description of CAP ref:
Component: Impact:
PI&R-(P.2}
PI&R -(P.2) Operating experience experience*- The licensee uses operating experience (OE) Impact OEis CA Operating information, including vendor recommendations and internally [l!J Yes IE] reviewed but 1157726 12 Experience generated lessons learned, to support plant safety. Specifically (as 0 No some issues applicable)::
applicable) identified in CA
- The licensee systematically collects, evaluates, and communicates to OE are not 1157726 - 16 affected internal stakeholders in a timely manner relevant internal and evaluated externalOE.
external OE. nor are
- The licensee implements and institutionalizes OE through corrective changes to station processes, procedures, equipment, and actions training programs. properly implemented.
Relevant changes to station processes, procedures, eqUipment and training programs are not effectively implemented.
(ReI)
(RC1)
FP-G-RM-Ol..
Form retained in accordance with record retention schedule identified in FP-G-RM-OI Fonn
- Safety Culture Impact Page 74740f81 of81 Safety Culture Description of Component Impact Description of CAP ref:
ref:
Component: Impact:
PI&R -(P.3) Self- and Independent Assessments - The licensee conducts self- and Impact Assessments CA Self- independent assessments of their activities and practices, as appropriate, IRl
!&l Yes are only 1157726-17 Assessment to assess performance and identify areas for improvement. Specifically 0 No included as applicable)::
(as applicable) part of the
- The licensee conducts self-assessments at an appropriate overall RP frequency; such assessments are of sufficient depth, are program comprehenSive, are appropriately objective, comprehensive, se~-critical. The objective, and are self-critical. itse~. The itself.
licensee periodically assesses the effectiveness of oversight groups RMSP needs and programs such as CAP, and policies. a separate
- The licensee tracks and trends safety indicators which provide an requirement accurate representation of performance. for
- The licensee coordinates and communicates results from assessments assessments to affected personnel, and takes corrective actions to ,,based based on signrricance.
address issues commensurate with their Significance. prog ram risk ,
exposure, in order to be se~-
more self-critical.
(CC1)
Form retained in accordance with record retention scbedule Fonn schedule identified in FP-G-RM-O FP-G-RM -0 II..
- Safety Culture Impact Page 75 of81 of 8 1 Safety Conscious Work Environment (SCWE)
Culture Safety Cu lture Description of Component Impact Description of CAP ref:
Component: Impact:
SCWE-(S.l)
SCWE-(S.1) Env ironment For Raising Concerns - An environment exists in which Environment Impact None None Environment employees feel free to raise concerns both to their management and/or andlor 0 Yes forr Raising fo the NRC without fear of retaliation and employees are encouraged to 00 No Il1l Concerns raise such concerns. Specifically (as applicable):
applicable) :
- Behaviors and interactions encourage free flow of information related to raising nuclear safety issues, differing professional opinions, and identifying issues in the CAP and through self opinions, assessments. Such behaviors include supervisors responding to employee safety concerns in an open, honest, and non-defensive non*defensive complete, accurate, and forthright information manner and providing complete, to oversight, audit, and regulatory organizations.
organizations. Past behaviors, behaviors, actions, or interactions that may reasonably discourage the raising actions, of such issues are actively mitigated. As a result, personnel freely and openly communicate in a cleB!clear manner conditions or behaviors, such as fitness for duty issues, which may impact safety; and personnel raise nuclear safety issues without fear of retaliation.
- IIFF alternative processes (i.e.,
(Le., a process for raising concerns or resolving differing professional opinions that are alternates to the licensee's corrective action program or line management) for raising safety concerns or resolving differing professional opinions exists, THEN they are communicated, accessible, have an option to raise issues in confidence, and are independent, in the sense that the program does not report to line management (Le., (i.e., those who would in the normal course of activities be responsible for addressing the issue raised).
raised).
Fonn retained iinn accordance with record retention schedule Form identi.fied in FP-G-RM-O I.
schedu le identified
- Safety Culture Jrnpact lmpact Page 76 of81 Safety Culture Description of Component Impact Description of CAP ref:
Component: Impact:
SCWE -(S.2)
SCWE-(S.2) Preventing, Detecting, and Mitigating Perceptions of Retaliation - Impact none none Preventing, A policy for prohibiting harassment and retaliation for raising nuclear 0 Yes Detecting, safety concerns exists and is consistently enforced in that:. IRl 00 No and
- All personnel are effectively trained that harassment and retaliation Mitigating for raising safety concerns concems is a violation of law and policy and will Perceptions not be tolerated.
of Retaliation
- Claims of discrimination are investigated consistent with the content of the regulations regarding employee protection and any necessary corrective actions are taken in a timely manner, including actions to mitigate any potential chilling effect on others due to the personnel action under investigation.
- The potential chilling effects of disciplinary actions and other potentially adverse personnel actions (e.g., reductions, outsourcing, and reorganizations) are considered and compensatory actions are taken when appropriate.
Form retained in accordance with record retention schedule identified in FP-G-RM-O I. 1.
- Safety Culture Impactlmpact Page 77 of 81 Other Safety Culture Components (OTH)
This section describes components of safety culture which are not associated with cross-cufting cross-cutting areas. These components, when combined with cross-cutting area components comprise the safety culture components. Components in this section should be considered if any of the cross the cross-cufting cutting areas align to a root or contributing cause.
Safety Culture Description of Component Impact Description of CAP ref:
Component: Impact:
OTH-(O.l)
OTH -(O.l) Accountability - Management defines the Ihe line of authority and Impact none none Accountabilit responsibility for nuclear safety. Specifically (as applicable) applicable):: 0 Yes y
- Accountability is maintained for important safety decisions in that [R]
lID No the system of rewards and sanctions is aligned with nuclear safety policies and reinforces behaviors and outcomes which reflect safety as an overriding priority.
- Management reinforces safety standards and displays behaviors that reflect safety as an overriding priority.
- The workforce demonstrates a proper safety focus and reinforces safety principles among their peers.
Fonn retained in accordance with record retention schedule identified in FP-G-RM-Ol.
Form FP-G-RM-O I.
Attachment Auachment 7 - Safety Culture Impact Page 78 of 81 Safety Culture Description of Component Impact Description CAP ref:
Component: of Impact:
- (0.2)
OTH -(0.2) Continuous learning environment - The licensee ensures tthat hat a Impact Adequate AR Continuous learning environment exists. Specifically (as applicable): 00 Yes training has 011Sn26 -
01157726 Learning
- The licensee provides adequate training and knowledge o0 No not been 20 Environment transfer to all personnel on site s ite to ensure technical provided to competency. ensure
- Personnel continuously strive to improve their knowledge, skills, skills, personnel and safety performance through activities such as benchmarking, performing being receptive to feedback, feedback, and setting performance goals. The RMSP licensee effectively communicates information learned frorn from internal duties have and external extemal sources about industry and plant issues. the required technical competency.
(CC2).
OTH -(0 .3)
OTH-(O.3) Organizational change management -Management uses a Impact none none Organizationa coordinating , and evaluating the safety 0 Yes systematic process for planning, coordinating, I Change impacts of decisions related to major changes in organizational 00 No Management structures and functions, functions, leadership, policies, policies, programs, programs, procedures, and resources. Management effectively communicates such changes to affected personnel.
OTH Safety Safety policies - Safety policies and related training establish and Impact none none Policies reinforce that nuclear safety is an overriding priority in that: 0 Yes
- These policies require and reinforce that individuals have the right 00 No and responsibility to raise nuclear safety issues through available means, including avenues outside their organizational chain of command and to extemal external agencies, and obtain feedback on the resolution of such issues.
- Personnel are effectively trained on these policies.
- Organizational decisions and actions at all levels of the organization are consistent with the policies.
poliCies. Production, cost and schedule goals are developed, communicated, communicated, and implemented in a manner Form retained in accordance with record retention retentjon schedule identified in FP-G-RM-O I.
- Safety Culture Impact Page 79 of 81 that reinforces the importance of nuclear safety.
- Senior managers and corporate personnel periodically communicate and reinforce nuclear safety such that personnel understand that safety is of the highest priority.
Conclusions Conclusions and comments from Cross Cutting Element Review:
The evaluation of the safety culture impacts reveals several programmatic flaws that need to be addressed. The issues identified during this assessment have been adequately addressed in the root cause evaluation corrective actions.
Corrective action 1161 675 has been written to evaluate the extent of 1161675 condition of these safety culture issues at the site.
Form retained in accordance with record retention scbedule schedule identified in FP-G-RM-O I .
- Safety Culture Impact of81 Page 80 of 81 Glossary of Terms used in this report Acronym Meaning CAP Corrective Action Program CFR Code of Federal Regu lations Regulations DOT Department of Transportation IAW lAW In Accordance With LAS Large area smear (also, masslin)
LSA Low Specific Activity LTD Limited mRlhr Milliroentgens per hour mremlhr rnremlhr MiJlirem per hour Millirem OC On contact reading OE Operating Experience RAM Radioactive material RMSP Radioactive Material Shipping Program RP Radiation Protection RPIP Radiation Protection Implementing Procedure RPM or Radiation Protection and Chemistry Manager RPCM RPT Radiation Protection Technician RWSC Radioactive Waste Shipping Coordinator SCO Surface Contaminated Object SFP Spent Fuel Pool Form retained in accordance with record retention schedule identified in FP-G-RM FP-G-RM-OI.
-OI .
- Safety Culture Impact [mpact Page 81 of of8181 AttachmentS Root Cause Evaluation Charier Charter CAP AR #0 Il 57726
- 01157726 Manager Sponsor: Bob Dob Hite Problem Statement:
Wednesday, 10/3012008,"
On Wednesday. 10/30nOOS, a shipping container contai ne r was received by the Waltl Mill site that exceeded IOCFR part 71.47 limits for shipping radioactive materials. This was u a violation of Prairie Island procedure D D11.7.
11.7.
- 6. 10.6, exceeding 200 mremlhr section 6.10.6. mrcmlhr on \Ht contact conlac t with the shipping contaicontainer ner on on an open t",nsport.
trnnsport. The 3 11677) was shipped from container (Box 311677) from the Prairie Island facilit faci lityy and co nUtined fuel contained fuel sipping equipme equipment.nt .
Investigation Scope:
The evaluation will determine the root cause of exeeedlOgexceeding DOT shipping limitations a, as required by 10 CFR part 71.47.
pan The scope of the review will include an investigation of the methods used to determine radiation levels of the components shipped, shipped. .,.
as well as methods for verifying verlfytng dose rates on the exterior of the shipping container and the trailer. The investigation will also try to determine the most likely contributor of the changing dose.
dose, where the material contributing to the tbe high dosc dose rates came from and why lhe the dose rates organi'tional and industry weaknesses that changed. Additionally. the RCE will determine any organi7Altionai thm contribute to the probability of incurring lransport transport issues relnted related to radiation radiati on dose limits.
Investigation Methodology:
The team will use interviews. FMEA.FMEA, cause and effects ana lysis and why staircases. and other methods analysis listed in FG*PA*RCE*O FG* PA-RCE*OI. secti on 5.9.
I, section I. to determine 5.9.1, detcrmine the root roOl cause for the failure to adequOlely control n adequately control a radioactive S shipmen hipment.!.
Team Members:
Tea Tcam m Leader Jeff leClair Operations Team Member Monti rep Fleet RP Team Member Myke Mal.7.i tcllo Matzitello RP/Chem Team Member Jeff Kivi (RCE qual) Lice nsing Licensing Menlor Team Mentor Gene Woodhouse Perfonnance Assessment Performance Assessmenl Field Team SCOII Nelson Aeet RPM Fleet Field Tcam Team Clay Swect Sweet RP/Chem Milestones:
Date Datc Assigned Assigned:: 1II07l0S 11/07/08 Status Update:
Updatc: ///12/08. /11/9108
//112/08, /1119/08 Draft Report: 11/17/08
//1/7/08 Report; Final Report: 1112/IOB
//12//08 Communic8tio~
Communications Plan:
Updates to PARB .,.
Update< as per milestones.
milestones.
Initial communication made to sUllion station via Clock Reset Red Shee\. Sheet.
Follow-up to the NRC via established processes.
Follow*up Approved: Bob Hlte Hlle Date: 11/06108 11106108 Management Sponsor Approved by: Screen Team 1 / PARB on 11/07/08 11107/08 Date Dzue Form Foml retained in accordance with record retenlion retention schedule identified in FP-G-RM FP-G-RM-Ol. *0 I.