ML102460633
Text
QF-0433, Rev 2, (FG-PA-RCE-OI)
(FG-PA-RCE-O I) RCE Repon Template Page 31 of81 Page310f81 V111.
VllI. Data AnaJysis A. Information & Fact Sources Interviews were conducted with the following group groups::
- Radiation Protection Specialists (in -house and contract) - 023 (in-house
- Radioactive Material Shipping Coordinators - 014
- ALARA Planner - 023
- Waltz Mill Personnel - 0D33 NSP000035B
- Radiation Protection department supervisors - D23 0 23
- Extent of Cause Interviews - 084 D84 The following data sources were used to obtain information in suppon support of this root cause evaluation:
cvaluation:
055, 061,
- Fleet Procedures - D55, 064, D65, D61 , D64, 065 , 067, 087 , 095, D67 , D87, D95 ,
029, D29, 036, D37, 037,038, D38, 039, D39, 040, 041 , 042,043,044, 042, D43, D44, 045,046, 045, 046, 085,086, D85, D86, 088,089,090, D88 , D89, D90, 091,092,093,094, 096,0105,0106, D91 , D92, D93 , D94, D96, D105 , D106 ,
- Industry operating experience - D52,052, 053, 066 D53, D66
- Photographs of fuel sipper, components and shipping container - 027 D27
- Vendor Radiation Surveys - 01 DI , 08 , 010.01 010. D12, D35 2, 035
- Site Radiation Surveys (a (as listed Listed in references section ) - 04, D4, 05 D5 , 09, D9, 015, DIS ,
DI7 017
- Written [nvolved - D24, Wriuen Statements from Individuals Involved D31 , 034 024, 031 D34
- Extent of Condition AR Search - 083 D83
- Meter Calibration Data Sheets - 069,D69, 070, D70, 071D71 , D72, D73,, 074 072, 073 D74
- Security logs - 020 D20
- Code of Federal Regulations - 016, D16, 0D107 I07 , 0D108, DI1 2 I08, 011
- Communications (e-mail and phone conversations) with various site and neet personnel- 032 D32,, 021 , 06, D6, 07, D7 , OliO DIIO
- Root Cause Informational Infomlational Literature - 030 D30
- SOMS Narrative Log - 022 D22
- NRC web site -047,
- 047, D48 048 , 049, 050, D50. 051, D51, 062, D62, 063, D63, 0104 DI04
- ALARA planning documents for 2R25 fuel sipping - 054, D54, 068 D68
- Vendor description of services and equipment- 056, 056. D59, D60 059, 060
- Shipping Documentation - D57. D58.
057. 058,
- Site web page - 075 D75
- OE evaluation records and guidelines- 097., 0D 109 guidelines- 097 I09
- Failure mode tables - 098 D98
- Calibration and linearity checks of instruments - 0103 D 103
- Evaluation from industry Industry Expert Expen of survey data - 0D 10 I. 0D I02 101,
- Communication between Westinghouse and the state of Pennsylvania - 0DIOO I00
- 2R25 scope change record - 0Dill III Form retained in accordance with record retention schedule identified in FP*G-RM FP-G-RM-OJ
-OI..
QF-0433, QF-0433. Rev 2. 2, (FG-PA-RCE-O II)) RCE Report Template Page 32 of81 or81 B. Evaluation Methodology & Analysis Techniques Data for this thh evaluation was collected primarily by interviews.
interviews, statements. records reviews, photographs. investigation and surveys of the shipping container at Waltz reviews.
Mill by the field team members and Westinghouse staff.
Analysis of the data was performed using the following methods:
- Task Analysis (Attachment II))
- Barrier Analysis (Attachment 2)
- Change Analysis (Attachment 3)
- Event and Causal Factors Charting Chalting (Attachment 5)
- Why Staircase Analysi Analysiss (Attachment 6)
- Evaluation of Safety Culture Impacts (Attachment 7)
C. Data Analysis Summary Data analysis Summary - The data analysis types were selected based on the type of issue the rOot root cause evaluation was to evaluate.
The following evaluation techniques were used to identify root and contributing causes from information collected during interviews and reference documents:
documents :
- Task Analysis: This analysis was used to determine the tbe appropriate tasks for a 'typical
' typical
radioactive material shipping program. The analysis also was used to determine.
determine, later.
later, which actions were not appropriate and how the actions contributed to the root causes.
- Event and Causal Factor Charting: This method produced a visual timeline of the event OE was received and distributed for information only from the time the latest relevant DE purposes at Prairie Island to realization that a DOT radioactive material shipment regulation cau es (event would not have occurred without these in place).
had been exceeded. Root causes place),
event). and inappropriate actions (who did what contrary contributing causes (worsened the event),
to a requirement) are identified on the chart. A noteworthy feature of the chart is the period of time between 10/29/08 and 10/30/08 10/30108 that was established estabJjshed as the time during which the cable containing the discrete particle shifted within the shipping container.
- Why Staircase Analysis: Each inappropriate action identified on the event and causal factor chart was further evaluated using why staircases in order to better understand the underlying reasons. "Why" was asked repeatedly until the point at which excuses began to replace legitimate reasons.
- Evaluation of Safety Culture Impacts: this evaluation was used to determine if there were any human performance issues identified in the evaluation of the rad shipping issue. The results of this evaluation were used as input to a site human performance perfonnance evaluation to determine if there are human performance perfomlance issues at the site that require broader scope corrective actions. The HU evaluation (other than the initial input) was carried out separately from the RCE evaluation of the rad shipping issue.
Form retained in accordance with record retention schedule identified in FP-G-RM-O I.
QF-0433.
QF-0433, Rev 2, (FG-PA-RCE-OI) RCE Report Template Page 33 of81 of 81
- BalTier Barrier Analysis: This analysi analysis was framed from the perspective of the Prairie Island picture of excellence and was used to determine departures from standards. In this analysis, it became apparent that the requirement that a survey find all discrete particles was not proceduralized and would not provide an effective barrier to prevent the rad shipping issue from occurring again.
again.
- Change Analysis: This analysis was used to determine if there were any initiating issues sippel' design) and also, if there were any changes in that were not properly identified (fuel sipper methodologies or worker practices that may be needed to provide barriers in the tbe future (watching the loading of containers, wrapping equipment with possible discrete particles and loose parts).
- Analysis of Procedures - This analysis was completed by a contract facility familiar with radioactive material shipping regulations and requirements. This evaluation determined that the industry typically relies on personal knowledge and also that there was little or no connection between what RPTs and RWSCs do in their respective procedures. Thi Thiss communication disconnect represented severa severall failed barriers.
D.
D. Failure Mode Summary The following codes were applied to the root cause and contributing causes:
Inappropriate Actions are coded for Human Error Type (GEMS), Human Perfonllance Performance Failure Mode (HP), Process Related Organizational I Management Re lated Failure Mode (PR) and Organizational/Management applicable.
Failure Mode (OM) if applicab le. Root Causes and Contributing Causes are coded for PR and OM on only ly (due to not being individual in nature)
IAl IA I - Workers did not package tbe the fuel sipper sippel' to prevent shifting GEMS - Knowledge Based HP - K7 - Flawed Analytical Process or Model, Insufficient knowledge of codes, standards, design basis, licensing basis, regulations, etc. needed to perform the task.
PR - ARARII - Critical Actions Not Verified, Critical actions required to successfully veri fi ed within the process.
perform a task are not verified RR6 - Methods Not Clearly Described, Action(s) are required by the document or instruction, but the method to accomplish the actions is not clearly specified by the document or instruction.
OM - F6 - Inadequate Program Management, Inadequate oversight of critical work processes to ensure they function smoothly and effectively.
Form retained in accordance with record retention schedule identified in FP-G-RM-O I. I.
QF-0433, QF-0433. Rev 2.2, (FG-PA-RCE-O I) RCE ReportRepon Template Page 34 of81 of8 1 IA2 - RWSC did not verify survey was adequate for shipping GEMS - Rule Based HP - J5 - Inadequate Verification, Verification. Insufficient verification of the facts.
facts, and is usually based upon inaccurate information infonnation or a lack of information.
infonnation.
PR - AR5 - No Acceptance Criteria, Criteria. No acceptable perfonnance parameters have been established for the process, process. procedure or task.
OM - F6 - Inadequate Program Management, Management. Inadequate oversight of critical work processes to ensure they function smoothly and effectively.
IA3 - Shipping was not specifically addressed in WO 367253 as required by FP-RP-JPP-O I. I, step 5.5.
GEMS - Knowledge Based HP - K2 Unfamiliar or Infrequent Task, Ta k. The shipping of fuel handling equipment is an infrequent evolution.
PR - RR2 Actions Not Clear.
Clear, Work order was not specific in regards to sending the fuel sipping tools back to Westinghouse.
OM - F4 Inadequate Planning.
Planning, Shipping the sipping equipment offsite should have been included in the work order.
CCI Industry Experience has not been effectively incorporated into ioto the RMSP, RMSP.
PR - AR4 - No Process Monitoring, Monitoring. There is no established means of monitoring the success or failure of the process.
OM - F6 --inadequate Inadequate Program Management, Management. Inadequate oversight of critical work processes to ensure they function smoothly and effectively.
C5 - Inadequate inadequate Self Assessment.
Assessment, A failure to continually encourage feedback, feedback . or look at better ways to perform.
CC2 The training and certification programs for RP personnel who perform shipping s hipping related activities do not meet industry standards, standards.
PR - RR5 - Actions Not Tied to Another Process When Necessary, Necessary. The action(s) contained within one document or instruction does not reference supporting supponing documents or instructions when necessary.
OM - F4 - Inadequate Planning.
Planning, Deficiencies in detennining determining what work must be done, done. by whom.
whom, when.
when, and how long it will take.
Form retained in accordance with record retention schedule identified in FP-G*
FP-G RM-O I.
QF-0433, Rev 2, (FG-PA-RCE-O (FG-PA-RCE-Ol) I) RCE Report Template Page 35 of 81 RCI - Radiation Protection and Chemistry procedures do not describe the methods required to successfully evaluate, package, and ship materials in accordance with 49CFR173 and 10CFR71.
PR - RR6 - Methods Not Clearly Described, Action(s) are required by the document or instruction, but the method to accomplish the actions is not clearly specified by the document or instruction.
OM - F6 - inadequate Inadequate Program Management, Management. Inadequate oversight of critical work processes to ensure they function smoothly and effectively.
RC2 - The significance the site has assigned the Radioactive Material Shipping Program (RMSP) does not align with the potential adverse consequences.
PR - AR5 - No Acceptance Criteria, No acceptable performperformance ance parameters have been established for the process, procedure or task.
OM - F3 - Inadequate Prioritization, Deficiencies in determjning determining which work takes precedence over other work.
Form retained in accordance with record retention schedule identified in FP-G-RM FP-G-RM-O -Ol.
I.
QF-0433, QF*0433, Rev 2, (FG*(FG-PA-RCE-OI)
PA*RCE*OI) RCE Report Template of811 Page 36 of8 IX. Root Cause and Contributing Causes The evaluation was completed with an overall determination dctenllination the Radioactive Radioacti ve Materials Shipping Sh ipping Program is less than adequate.
adequate.
The tenn rad radioactive ioactive material shipping program' program ' is defined as oversight of those events involving the surveying, packaging, and loading of radioactive material into containers, as well as the loading and strapping of the containers on transport vehicles, and confirmatory surveys of loaded equipment, and travel on the public transportation system, through confirmatory surveys by the receipt organization. These actions mu st be completed every action s must time a radioactive material shipment is completed and sent out from from Prairie Island. When When receiving radioactive material shipments, the shipping program is responsible for the initial receipt inspections conflfTl1atory surveys, and adequate disposition in spections of the material, confirmatory di sposition of the shipping container to an appropriate storage area. area.
The root causes of the radioactive material shipment issuc issue have been identified as:
RCI. Radiation Protection and Chemistry procedures do not describe the methods RCt.
required to successfully evaluate, package, and ship materials in accordance with 49CFR173 and 10CFR71.
IOCFR7I.
Specific examples of this include:
include:
I (RPlPs) and Radioactive Material Shipping Radiation Protection Procedures (RPIPs)
Procedures (0 II) do not coordinate activities between the two programs (DII) 2 There is a heavy reliance on RMSP personnel knowledge instead of well defined approved procedures 3 Step 6.9 of DII.7 011 .7 is vague with little other guidance in approved documentation on how to evaluate, package, and load rad materials.
There were no prescribed steps to load the shipping container or survey the equipment going into the container, as the RMSP is typically maintained outside the work (outage and on line) process.
RC2. The significance the site has assigned the Radioactive Material Shipping Program (RMSP) does not align with the potential adverse consequences.
Spec ific examples of Specific o f this include:
I Risk perception did not match real risk.
2 There is a heavy reliance on an individual individua l instead of the program.
3 simi lar events were not effective.
Corrective actions from previous similar 4 Risk significant RMSP RM SP evolutions are not covered by the work control process -
no tasks or priorities established.
5 There was no supervisory oversigbt of the shipping evolution.
The RWSC was the signatory authority for rad shipments, regardless of material, matenal, destination, risk . There were limited programmalic activity, or risk. programmatic checks and balances to ensure important decisions were the responsibility of a single decision maker.
Form retained in accordance with record retention schedule identified in Fp*
Fonn FP-G-RM-O G* RM*OII..
QF-0433, Rev 2, (FG-PA-RCE-OI) RCE Report Template Page 37 ofof8181 Figure I: RMSP schematic representation
!Evalualc IEvaluate iWrapping
[Wrapping r---onLaincr r-ontainer ~urvey to ,-Dmplete r-0mplete
!Material
!Mmerial f-ouding
"".ding hip phip apcrwork
- ~ Composi Composition tion \------~
~~----~ ~----~) ~-----)
-* Confi ConfigUnllion gumti on V
-* History DOT ' Package'
- Rad ialion Survey Radiation Figure II provides graphical detail of ' typical typical RMSP components involving a shipment. The historic involvement of the RMSP at PI has been in the last two activities (survey of the shipment and completing the necessary paperwork, with heavy reliance on the radiation protection group for Ihe the first three activities. The radiation protection group focufocuss in the flrst first three activities was not appropriate to address all RMSP requirements, due to other priorities and a lack of a clear understanding of RMSP requirements.
Levels of supervisory involvement and approvals must be commensurate with the risk involved with each shipment. There was no guidance in place to determine who or what level of involvement was necessary for a given shipment.
During this evaluation, there was a lot of focus on the initial survey of the equipment. The inappropriate survey represents one of the initial barriers that could have havc prevented the event from occurring. Detailed analysis, including why staircases and event and causal factor charting, determined the inadequate survey was an inappropriate action in the chain of factors up to the event. These analyses were completed to determine causal factors that were that led lip considered when developing the root and contributing causes.
The root cause evaluation identified the following contributing causes:
CC I Industry Experience has not been effectively incorporated into the RMSP. RMSP, Specific examples of thi s include:
II Corrective actions as a result of OE evaluations are not effectively incorporated.
2 Industry benchmarking benchmarldng is not used to evaluate program health. health.
CC2 The training and certification programs for RP personnel who perform shipping related activities do not meet industry standards, standards.
Specific examples of this include:
I Tnterviews Interviews identified there is no fonnalformal r'dd rad shipping qualification above the minimum DOT requirements for RP technicians observing packaging evolutions.
2 Some personnel perfonniog performing RMSP activities were not familiar with RMSP requirements and are not qualified 49 CFR, subpart H.
Form retained in accordance with record retention schedule identified in FP-G-RM-O FP-G-RM-Ol. I.
QF-0433, Re Revv 2, (FG-PA-RCE-OI (FG-PA-RCE-OI)) RCE Report Template 81 Page 38 of 81 3 The RMSP has no provisions for ensuring qu alifications of personnel involved ensurin g qualifications in volved in the packaging of rad material shipments per 49 CFR Subpart H. H.
4 There are no site si te programs th at are utilized for tracking 49 CFR, subpart H that qualifications.
Corrective Actions Corrective Actions to Restore (broke-fix) and Interim Corrective Actions (mitigation)
I. Stop work order from Xcel Energy CNO to prevent any further shipment of radioactive materials from Prairie Island and Monticello (complete).
(complete).
- 2. A quarantine of all rad shipping procedures (0 (DIIXX I IXX series) was processed (Mitigation) (complete).
PA to verify and gather information (complete).
(complete).
44.. An initial RP evolution risk matrix was issued to provide guidelines to RP management staff regarding risk significant evolutions in the Radiation action s Protection field and providing levels of oversight, approval and actions required (complete).
S.
S. Fleet (internal) Operating Experience was distributed (complete).
(complete).
- 6. A root cause team was formed to perform the evaluation regarding this issue (complete).
Form retained in accordance wi with tb record retention schedule schedu le identified in FP-G-RM-O FP-G-RM -OI.
QF-0433, Rev 2, (FG-PA-RCE-OI)
(FG-PA-RCE-O I) RCE Report Template or81 Page 39 of81 Corrective Actions to Prevent Recurrence (CAPRs) and Effectiveness Reviews Cause to Action Matrix Cause 1 Problem Corrective Action Owner 1 Due Date CAPROI157726-06:
Upgrade radioactive material shipping procedures 011.7, D I 1.7, 0 I 1.6, DII.13, 011.11 , DI1.6, 011.13, and DII.14 0 I 1.14 as appropriate to Owner: RPM provide the following specific information: Due Date: 2/6/09
- Define involvement levels for RWSC personnel per onnel for risk Completed: 1129/09 significant shipment evolution evolutionss
- Define supervisory approval requirements.
requirements.
CAPROI157726-07:
Upgrade radioactive material shipping procedures 011.7 D 11.7,,
01I 1.11 D 1.11,, D 11.6, 0D I 1.13, 011.6, 1.1 3, and 0 I 1.l4 1.14 as appropriate to provide the following specific information:
information :
- Guidance on appropriate blocking and bracing, and use of small diametcr diameter probe surveys during risk significant sign.ificant RCI - Radiation hipment activities.
shipment Protection and
- del etc 011.10, DII.1 delete Dl 1.2,, 011.4, 011.122,, 011.2 DI1.4, 011.8 DI1.8 , and 011.9 DI1.9 Chemistry Owner: RPM
- Require a RWSC assistant trained individual procedures do not Due Date 2/6/09 (minimally) bc be present during packagi ng of all risk packaging ri sk describe the methods lI29/09 Completed: 1/29/09 significant equipment scheduled to be shipped.
required to
- Require a R RWSC WSC assistant trained individual successfulJy successfully (minimally) be present during loading of shipping evaluate, package, containers with materials that contain risk significant and ship materials in equipment scheduled cheduled to be shipped accordance with
- If IT a radioactive package contains high risk ri sk items, then 49CFR 173 and ensure the shipment uses closed transport as the method IOCFR71.
of shipment.
CAPRO I157726-13:
CAPROI157726-13:
Generate RPIP 1303 (Packaging of Radioactive Material):
Any materials that have a possibility of containing a discrete particle be labeled on the package or on the RAM tag.
Owner: RPM Due Date: 2/6/09 Add a note 10 to the precautions section that di~crete discrete Completed: 1/29/09 particles be annotated on the wrapping or on !lIe the RAM tag to ensure shippers are notified of possible discrete particles.
particles.
Provide guidance for discrete particles in the procedure.
Form retained in accordance with record retention schedule identified in FP-G-RM FP-G-RM-O -Ol.
I.
QF-0433, QF-0433 , Rev 2. 2, (FG-PA-RCE-Ol)
(FG-PA-RCE-OI) RCE Report Template of 81 Page 40 of81 Cause / Problem Corrective Action Owner / Due Date CA 01157726-22:
Revise RPIP 11 22 to require:
I 122 Change any references to hot particles 10 to discrete particles.
RC I - Radiation Protection and Any materials being packaged that have been identified as Chemistry having discrete particles are labeled on the package or tag procedures do not as containing discrete di screte particles.
describe the methods Owner: RPM required to Identify areas where discrete particles may exist (refueling Due Date: Date: 2/6/09 successfully cavity, spent fuel pool pool,, primary system , and discrete Completed: 1128/09 eva luate, package,
- evaluate, particle areas) and ship materials in accordance with di screte particles Require any equipment that may have discrete 49CFR I173 73 and that is being surveyed and may be shipped require the IOCFR71.
survey be sent to the RWSC and the RWSC be notified prior to completing the survey.
Reference 0 IIII procedures RCI - Radiation Protection and Chemistry procedures do not describe the methods CA 0 I 157726-24: Owner: RPM required to Revise RPIP 1122 to require the use of a meter with an Due Date: 02128/09 successfully audible response when surveying for discrete partic les.
di screte particles. Completed: 2120/09 2/20/09 evaluate, package, and ship materials in accordance with 49CFR 173 and IOCFR71.
CAOI157726-30:
FP-WM-PLA-OI, Revise FP-WM -PLA-OI, Work Order Planning Process to RC2 - The priorities address rad shipping tasks. For example:
that the site has given the 5.10, item #21 - "Add support tasks or
- Section 5.10. Owner: Director Radioactive Material resourees as necessary. For example, a new/separate task Fleet Ops resources Shipping Program for shipping radioactive materials." Standardization do not align with the
- The Detailed Work Order Package section of Due Date: 10/8/09 potential adverse Attachment 2 - "Work that has a highbigh risk due to consequences of personnel safety or radiological exposure (ALARA program failures tasks), including shipping of radioactive materials" materials" Fonn Form retained in accordance with record retention schedule identified in FP-G-RM-O FP*G-RM-O I.
QF-0433. Rev 2. (FG-PA-RCE-O J) I) RCE Report Template Page 41 of orBI 81 Cause /f Problem Corrective Action Owner f/ Due Date RC2 - The priorities CAO 1I 157726-31:
157726-31 :
that the site has Revise QF20 QF2010.IO. to address radioactive material shipping given the tasks. For example:
Radioactive Material Owner: Fleet RPM Owner:
Shipping Program Add an item to address shipments designated as IOf8/09 Date: 10/8/09 Due Date:
do not align with the Radioactive Material Quantities of Concern as high risk potential adverse shipments.
consequences of program failures Cause fI Problem Corrective Action Owner f/ Due Date Owner:
Owner: RP CA01164766:
CAOII64766:
Supervisor Provide a reference that directs personnel to use PINGP PlNGP 2115/09 Date: 2/15109 Due Date:
1400 Completed: 2/3/09 2/3109 Owner: RP Owner:
CAOII6476B:
CAO 1 164768:
Supervisor Extent of Cause Submit a training request to communicate that Date: 3/25f09 Due Date: 3/25109 Corrective Actions transporting chemicals via personal vehicles is prOhibited.
prohibited.
Completed: 312109 312/09 CAO 1164759:
I 164759: Owner: NOS Delete QCIM QClM -R-O
-R-OII Supervisor 2/15109 Due Date: 2115/09 Completed: 11I111 3/09 3f09 Form retained in accordance with record retention schedule identified in FP-G-RM-OJ.
FP-G-RM-O 1.
QF-0433, Rev 2, (FG-PA- RCE-O I) RCE Report Template (FG-PA-RCE-OI) 81 Page 42 of SI Cause / Problem Corrective Action Owner / Due Date CAPROI157726-14:
CAPROI157726- 14:
Add RMSP evolutions inLO into the ririsk sk matrix by updating procedure 5ASA WI .S.0. The matrix will include, W1 15 .8.0. include. for the rad shipping category, the following field s: s:
Moderate - Involves surveying or packaging of Owner: Plant radioactive equipment or waste with associated dose rates rares Manager
- e
- 40%
- 2:40% AND <80%
<SO% of any applicable shipping dose rate Due Date: 2/4/09 limit.
1129/09 Completed: 1/29/09 High - Involves surveying or packaging of radioactive equipment or waste with associated dose rates ;e:80% :2:S0% of any applicable shipping dose rate limit.
RC2 - The priorities Involves surveying or packaging radioactive equipment or tha thatt the si te has site waste from the Spent Fuel Pool or Reactor Cavity, given the excluding intact filters or resin.
Radioactive Material Shipping Program Note: Risk significant is defined as Medium and High do not align witb with the risk items.
potential adverse consequences of Update: Following completion of this CAPR, site Update:
program failures procedure 5A W] 15 SAW] .8.0 was deleted and replaced by fleet 15.8.0 FP-WM-IRM procedure FP-WM -IRM -OI, integrated Integrated Risk Ri sk Management.
Owner:
Owner: Director Currently, the !leet Currently, fleet procedure doe does not reference this Fleet Ops CAPR. To ensure the actions taken by CAPRO I 157726-Standardization Standard ization 14 are retained in the fleet process, CAPROI157726-28 CAPRO 1157726-28 Date: 10/S/09 Due Date: 10/8/09 was initiated to revise QF-20 I0, Work Order Risk Screening Worksheet, to add details for risk determination for rad shipping activities. Additionally, CAPO I1185108 IS51 OS has been generated to ensure the CAPR is referenced in the fleet procedure and to document the potential for lost data/failure to incorporate CAPRs resulting from a RCE.
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 43 of 81 Cause I/ Problem Corrective Action Owner I Due Date RC I - Radiation EFROI157726-18:
Protcction and Protection Complete an effectiveness review of the rad shipping Chemjstry Chemistry program.
program. Effecti veness review will be completed by procedures do not direct observation of a risk significant shipment by a team Owner: RPM de cribe the methods describe comprised of an industry peer and site management. The Due Date:
required to observation will observe all aspects of the shipment from 11/01/09 successfully successfu lIy planning through release from the si site.
te. Effectiveness will evaluate, package, be determined by no sign ificant deficiencies noted in significant and srup ship materials in procedure quality or evaluation of risk.
accordance with 49CFR 173 and IOCFR71.
EFRO I 157726-19:
157726- 19:
Complete Complcte an effectiveness review of the RMSP by RC2 - The priorities completing an extemal external asse sment of the program.
assessment that the site has Effectiveness will be determined by no significant given the Owner: RPM deficiencies noted addressed by CAPRs of this evaluation.
Radioactive Radioacti ve Material Due Date:
Specifically, this evaluation will look for significant Shipping Program 11/01/09 procedure deficiencies in the RMSP, failure of the site to do not align with the properly evaluate an RMSP evolution for ririsk, sk, procedures potential adverse changes completed, training program fully implemented consequences of and qualified personnel proficient in qualification.
program failures.
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 I) RCE Repon Report Template Page 44 of 8811 Cause I1 Problem Corrective Action Owner 1 I Due Date CAO 1157726-12:
CAOI157726- 12:
Monitor Operating Experience evaluation eva luation methods as follows:
All OE evaluations applicable to the RMSP will be Owner: RPM reviewed by RPCM on an ongoing basis to determine if Due Date: 1/11110 1111110 appropriate applicability determinations are being completed.
CAOI157726-16:
Monitor Operating Experience review and evaluation methods as follows:
- OE screening packages will be reviewed by an RP Owner: RPM supervisor on an ongoing basis to determine if RMSP CCI -Industry Due Date: 1111110 applicable OE is properly screened for application to PI.
Experience has not Review will be provided to department depanment OE liaison or been effectively site OE coordinator.
incorporated into the RMSP.
CAOI157726- 17:
CAOI157726-17:
Add requirements for:
for:
- A focused self assessment assessmcnt for the rad shipping program Owner: PA at a frequency of every three years. This is in addition to Supervisor any other RP assessment requirements. Due Date: 2/28/09
- A periodic benchmarking for the rad shipping program Completed: 2/27/09 Complcted:
at a frequency of every three years.
EFROI157726-29:
EFRO I157726-29:
Conduct an effectiveness review of the additional OE Owner:
Owner: RPM reviews implemented under CAOI 157726- 12 and 16.
CAO 1157726-3/31110 Due Date: 3/31/10 Determine if such reviews need to continue. Initiate
[nitiate additional corrective actions for anydeficiencies any deficiencies noted .
Form retained in accordance with record retention schedule identified in FP-G-RM FP-G-RM-O -OI.
(FG-PA-RCE-OI)
QF-0433. Rev 2. (FG-PA-RCE-O I) RCE Repon Report Template Page 45 of of81 81 CalL'le 1 Cause / Problem Corrective Action Owner 1/ Due Date CC2 - The training CAOI157726-20:
and certification Establish a training and qualification for radioactive waste programs for RP coord inator assistant to be a specialist position to shipping coordinator Owner: Training personnel who perfonn tasks as described in RPlP perform RPLP 1303. Manager perform shipping Subpan H training.
Include requirements for 49 CFR Subpart Due Date: 5/31109 Date: 5/31/09 related activities do Generate a matrix which defines those activities to which Completed: 3127/09 not meet industry Subpan Subpart H qualifications apply.
standards.
CAOI157726-25:
CC2 - The training Add steps to Rad Shipping procedures that:
and certification
- Requires a comparison of equipment dose rates to programs for RP rates. if shipping container dose rates. do e rates on the If the dose Owner:
Owner: RWSC personnel who container are higher than the dose rates of the equipment Due Date:
perform shipping placed in the container, do not ship the container until an 03113/2009 03/13/2009 related activities do investigation has been conducted to determine the cause. 3/9109 Completed: 3/9/09 not meet industry
- Add a step in the Rad Shipping procedures that verifies standards.
Subpan H appropriate personnel meet 49CFR 172 Subpart 1-1 training requirements.
Other Corrective Actions
- CAP 1160060 I 160060 This was an identified issue with procedure deficiencies noted in the oD IIX II.X series of procedures. Actions will be taken to update references. delete references to strong, tight packaging. CAP initiated prior to completion of RCEO I 157726. CAP screening recognized that the suggested actions were addressed by the CAPRs and CAs in the RCE. Therefore.
Therefore, this CAP was appropriately closed to RCEO RCEOl157726.
I 157726.
- CAP 1161675 This CAP was to further evaluate safety culture issues identified in the RCE in areas not evaluated by the root cause to check for extent of condition. Completed 4/4/09.
Completed 4/28/09.
- PCR 01 166814 Change 089 to remove references to deleted procedures. Completed 01166814 2/3/09.
- CAP 01185108 0 I 185108 Document the potential for lost data/failure to incorporate CAPRs resulting from a RCE.
Form Fonn retained in accordance with record retention schedule identified in FP-G FP-GRMOI RM-OI..
QF-0433, Rev 2. (FG-PA-RCE-Ol)
(FG-PA-RCE-O I) RCE Report Template Page 46 of 81 Xl. References Doc # List DatelRev 1 HP Form 270A Rev 2 (03104) Westinghouse Radiological Survey 10/31/2008 10/31 /2008 Record Survey No. 2008-704-SC 2 CAP 01157726 PI Rad Shipment Arrives at Consignee above 10/31/2008 DOT Rad Limits 3 Trip Notes from Waltz Mill 11/3/2008 11 /3/2008 -
11/14/2008 11 / 14/2008 4 HP Form 270A Rev 2 (03104) Westinghouse Radiological Survey 11/4/2008 11 /4/2008 Record Survey No. 2008*372*R5 2008-372-R5 5 HP Form 2708270B Rev 2 (03104) Westinghouse Radiological Survey 11/14/2008 Record Survey No. 2008-755-SC 6 Memo from RPM Stopping Shipments 7 Summary of Discussion with NRC related to Potential Greater 1215/2008 than Green Finding 8 HP Form 270A Rev 2 (03/04) 2008*754*SC (03104) Survey No. 2008-754-SC 11/13/2008 9 PINGP 258, Rev. 13 Radiation Protection Survey Record 11/312008 WOlTask nla 10 HP Form 1058 (01/05) Record of Monitoring on Receipt of 10/30/2008 10130/2008 Radioactive Materials Receiving Shipment #1-324-2008
- 1*324*2008 11 011 .7 Radioactive Materials Shipment - LSAISCO/L LSAISCO/LTDTO Qty to a 10/29/2008 10/2912008 Licensed Facility Shipment #08-069 12 Radioactive Shipment Receipt Survey 1 1-324-2008
- 324-2008 11/312006 11/312008 13 011.7 Radioactive Materials Shipment - LSAISCO/LTO Qty to a Rev.
Rev. 15 Licensed Facility 14 Interview Notes - Rad Shipper 15 PINGP 258 Radiation Survey Record , Verification of Dose Rates 10/2912008 on Fuel Sipping Package for Shipment #08-069
- 08*069 (Dated 29-0CT-08 09:00) for WO 366884 16 49CFR Part 173 Radiation Level Limitations and EXClusive Exclusive Use Provisions 173.441 17 PINGP 258.258, Rev 13 Radiation Protection Survey Record 10/2312008 WOlTask 00367253 18 RPI P 1319 Loading LSA Boxes/Sea-land Containers Rev. 10 19 5AWI 3.6.4 Notifications Regarding Plant Media Sensitive Events Rev.
Rev. 14 or Conditions 20 History of Logged Messages for All Persons 10/29/2008 21 E-mail regarding Rad Shipper training program 1211912008 Form retained in accordance with record retention schedule schedu le identified in FP-G-RM-O I.
QF-0433, Rev 2, (FG-PA-RCE-OI)
(FG-PA-RCE-Ol) RCE Report Template Page 47 of 818I Doc # List DatelRev Date/Rev 22 Radiation Protection SOMS Narrative Log Search 10/23/08 10/23108 to 10/29/08 23 Interview Notes - RPTs, others 24 Trucker Statement 111712008 11!712008 25 RPIP 1135 RWP Coverage Rev. 19 26 WO 367253 - West: SIP Fuel Assemblies to support Cask Loading 27 Pictures from Waltz Mill 11 /3/08 -
11/3/08 11/4/08 11 /4/08 28 PI Shutdown log unit 2 11/212008 29 RPIP 1122 Hot Particle Program Rev. 13 30 Commonly Seen Cause & Effect Relationship 31 E-mail Westinghouse to Southern Pines Trucking & PI 10/31/2008 10/3 1/2008 32 E-mail from Xcel Fleet RPM to NRC, dated Thursday, November 11 /6/2008 11/612008 06,20087:13 AM 33 E-mail to Pion isotopic analysis 11/14/2 008 11/14/2008 34 E-mail from Westinghouse to PI 10/31/2008 35 Westinghouse Nuclear Services Departmental Procedure WM-HP-RAM-514 Rev 0 36 D11 D 11 Radioactive Material Shipment Rev 16 6/19/2007 37 D11.6 Radioactive Materials Shipment - N.O.S. - Other than Dll.6 3/29/2 006 3/29/2006 Irradiated Fuel- Not Exceeding HRCQ Rev 11 38 D11.10 Mixed Low-Level Radioactive and Hazardous Waste Dl1.10 3129/2006 (Mixed LLW) Shipment Rev 8 39 D11.11 Radioactive Materials Shipment - LSAISCO/LTD Qty in 4/10/2006 Exclusive Use Vehicle - to Licensed Processing Facility Rev 10 40 D11 .13 Radioactive Materials Shipment - Certified 4/1212006 Containerized Waste to Envirocare of Utah Rev 1 41 Radioactive Material Shipment - LLRW to Bulk Waste Disposal 4/1212006 Facility of Envirocare of Utah Rev 1 42 RPIP 1118 Conducting Radiation Surveys Rev 16 5/19/2008 43 4AWI*08.05.02 Radioactive Material Shipping Rev 11 MNGP 4AWI-08.05.02 44 MNGP form 5620 Instructions for Maintenance of Exclusive Use of Controls Rev 6 45 MNGP form 5877 Radioactive LSAISCO Shipment*
Shipment - in Exclusive use Vehicles Rev 5 46 MNGP form 5860 Master Radioactive Material Shipping Procedure Form retained in accordance with record retention schedule Fonn schedu le identified in FP-G-RM FP-G-RM-Ol.-O1.
QF-0433, Rev 2, QF-0433. (FG-PA- RCE-O I) RCE Report Template
- 2. (FG-PA-RCE-OI) Page 48 of 81 Doc # List DatelRev 47 NRC Detailed ROP Description 48 0308 Appendix D Technical Basis for Public Radiation Safety 6/25/2004 Significance Determination Process 49 OCFR71 .47 Ex1ernal 10CFR71.47 External Radiation Standards for All Packages 50 NRC Inspection Manual Inspection Procedure 95003 1/17/2002 51 NRC Appendix D Public Radiation Safety Determination Process 211212008 52 EA-06-253. Vermont Yankee NPS NRC inspection Report EA-06-253, 111712008 05000271/2006011 05000271 /2006011 53 Operating Experience Documents 54 ALARA Planning for 2R25 Fuel Sipping 1211212008 55 FP-PA-OE-01 Rev 10 Attachment 7 Expectations for Using OE FP-PA-OE-Ol 10/31/2008 10/31 /2008 56 Westinghouse Vacuum Canister Sipping Services brochure 511/2008 57 Shipping Bill of Lading 08-069 10/29/2008 58 SC-11-3556 SC-II -3556 Packaging Certification Documents 1215/2007 59 11 -3556-2-01 Shipping Canister Container Schematic Container 11-3556-2-01 Assembly SSB-300-40-7A-TRF Attachment 1 Container Final Inspection Report for Shipping ISB-300-4-7A1IP3-TRF Container ISB-300-4-7 All P3-TRF 60 11 -3556-2-01 Shipping Canister Container Schematic Container 11-3556-2-01 Assembly SSB-300-40-7A11P3-TRF Final Inspection Report 61 FP-RP-JPP-Ol Rev 4 RP Job Planning FP-RP-JPP-01 11 /26/2007
/2 6/2007 62 NRC Inspection Manual Chapter 0305 11/27/2007 63 NRC Inspection Manual Inspection Procedu re 95002 Procedure 10/16/2006 64 FP-G-DOC-03 Rev 5 Procedure Use and Adherence 713012008 65 FP-PA-HU-Ol Rev 6 Human Performance Program FP-PA-HU-01 4/24/2008 66 0E26644 Shipment of Radioactive Material Exceeds Contact 51712008 Dose Rate Limit 67 FG-PA-RCE-Ol Rev 14 Root Cause Evaluation Manual FG-PA-RCE-01 7/30/2008 68 RWPs associated with WO 367253 Form retained in accordance with record retention schedule identified in FP-G-RM-Ol.
FP-G-RM-OI .
QF-0433, Rev 2, (FG-PA-RCE-OI)
(FG-PA-RCE-OJ) RCE Report Repon Template or 81 Page 49 of81 Doc # List DatelRev Date/Rev 69 Calibration Certificate Certifi cate Eberlin Eberlinee E-600 Portable Radiation Monitor 8/25/2008 Body 70 Certificate of Calibration Eberline Teletector 6112B 61 12B /3/2008 11 /312008 71 PINGP 1642 Rev 0 MG Telepole Calibration Data Sheet 11 /5/2008 72 Certificate of Calibration Eberline SHP-270 with E-600 9/9/2008 73 Certificate of Calibration Eberline RO-2 5/2212008 74 Certificate of Calibration Eberline Teletector 6112B 61 12B 9/5/2008 75 RP & Chem Org Chart 76 Job Risk Assessment Matrix 77 aVask at Waltz Mill Things to Look at/ask 78 E-mail Root Cause Activities 11/10/2008 79 PINGP 1112 Rev 24 RCE Pre-Job Brief Attendance 11/10/2008 80 QF-0414 Rev 5 PI Site Clock Reset - Red Sheet OF-0414 Sheetfor for CAP01157726 CAPOl157726 81 Draft RP job risk assessment 82 Draft evaluation of 011 .7, RPIP 1319, and RPIP 1122 011.7, 83 Extent of Condition AR Searches 84 Interview Notes - Extent of Cause 85 OCIM-R-01 Inspection Requirements and Acceptance Criteria for QCIM-R-01 RAM shipment Inspection Points 86 RPIP 4518 Septic Tank Sampling 87 FP-SC-RSI-04 Material Return Receipt 88 014.8 Regulated Waste Management 89 014.5 Hazardous and Non-hazardous Materials Storage, Disposal and Labeling Requirements 90 MateriaVHazardous Waste PINGP 1400 Checklist for Hazardous Material/Hazardous Shipment 91 RPIP 3105 Preparing Oil , Fuel and Special Samples for Shipment 92 PINGP 1409 Checklist for Shipping Hazardous Material Samples to Chestnut Service Center 93 Containing Material HandlinQ/Removal 074 Asbestos ContaininQ Handling/Removal 94 Waste Xcel W Manaaement Guidance Manual aste Management 95 Safeguards Information FP-S-SGI-01 Control of SafeQuards 96 Inventory, Inspection SIP 4.5 Firearms Inventory. Inspection, Cleaning CleaninQ & Maintenance 97 1/112007 to 12131/2008 RP OEE for 1/1/2007 98 Failure Mode Tables 99 NRC Inspection Manual 0609 Appendix 0 2112108 Form retained in accordance with record retention schedule identified in FP-G-RM-O 1. I.
QF*0433, Rev 2, (FG-PA-RCE-Ol QF-0433, (FG*PA*RCE* OI ) RCE Report Template Page 50 of 81 81 Doc # List Date/Rev Westinghouse Email To State of Pennsylvania, dated Friday, 100 October 31 20085:52 PM 10/31/2008 Effective Dose Equivalent Rate from Surface of the Shipping 101 Container 1/212009 1/2/2009 Evaluation of Surveys of the Prairie Island Shipping Container 102 #17*0072 from Shipment #1-324-2008.
Serial #17-0072 #1*324*2008. 1/1/2009 103 Telepole linearity check for Radwaste shipment investiaation NRC Regulatory Issue Summary 2003-042003*04 Use of the Effective Dose Equivalent in Place of the Deep Dose Equivalent in Dose 104 Assessments 2113/2003 Rev6 Rev6.,
105 SAWI 5AWI 1S.8.0 15.8.0 Work Activity Risk Manaaement 3/26/08 Rev 13, 106 RPIP 1300, 1300 Control and Taaaina of Radioactive Material 6/3/08 107 10CFR20.1201 Occupational dose lim its for adults limits S/21 /1991 5/21 108 10CFR20.1301 Dose limits for individual members of the public S/21 /1991 5/21 109 OE screenina auidelines 110 Emails reaardina safety safetv sianificance determination 1/6/2009 111 2R2S 2R25 scope SCODe chanae record for WO 367253 112 40CFR190.10 7/1/2 113 ACE 00052837 lead blanket shipment to Kewaunee 6/28/01 114 011 011.7.7 previous revisions 12 1313,14 14 Supportina documentation for EOC Addendum 115 Suooortina 10/15/09 Form retained in accordance with record retention schedule schedu le identified in FP*G* RM*OI.
FP-G-RM-O