Text

Insp Rept 50-388/89-25 on 890901-02.Violations Noted.Major Areas Inspected:Licensee Evaluations & Corrective Actions Associated W/Unplanned Exposure to Contractor Performing Reactor Coolant Sampling Activities on 890831
	ML17156B363
Person / Time
Site:	Susquehanna
Issue date:	09/13/1989
From:	Bores R, Kotton J, Mcnamara N, Nimitz R, Pasciak W; NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	;
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ML17156B362	List: ML17156B361; ML17156B363;
References
	50-388-89-25, NUDOCS 8909260160
	Download: ML17156B363 (10)
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-" U. S.

NUCLEAR REGULATORY COMMISSION

REGION I

Report

No. 50-388 89-25

Docket No. 50-388

License

No.NPF-22

Priority

Category

C

Licensee:

Penns lvania Power

and Li ht

Com an

or

ln

ree

en

own

enns

vani a

18101

Facility:

Sus

uehanna

Steam Electric Station

Unit 2

Inspection At:

Berwick

Penns

lvania

Inspection

Conducted:

Se tember

1

and

2

1989

Inspectors:

lml z,

n

r

a

ion

pecla ls

o

,

o

ory

pec>a

>s

Approved by:

c amara

ora ory

ec nlclan

a

e

ascla

,

le

,

acl

1 les

a la ion

Protection Section

ores

le

,

Sectio

uen

s

a la ion

ro ec ion

Ins ection

Summar

Ins ection

on Se tember

1-2

1989.

Ins ection

Re ort No.

Areas

Ins ected:

Specla

, announced

radiological controls

and chemistry

lnspec

ion

o review the circumstances,

licensee

evaluations

and corrective

. actions

associated

with an unplanned

exposure

to

a contractor performing reactor

coolant sampling activities

on August 31,

1989.

Results:

Four apparent violations were identified (Failure to adhere to

raraiaVion protection procedures

as required

by Technical Specification

(TS)

6. 11, Details section

6; Failure to establish

reactor coolant sampling

procedures

as required

by TS 6.8

, Details section

6; Failure to perform

radiation surveys

per

10 CFR 20.201,

Details section

6;

and Failure to instruct

workers per

10 CFR 19. 12, Details section

6 ). In addition

one unresolved

item

was identified and involved the potential

overexposure

to

a contractor.

8+0~24io J (go

g

p DC

1.0

Individuals Contacted

DETAILS

1. 1

Penns lvania Power

and Li ht

Com an

R.Byram, Plant Superintendent

H. Riley, Health Physics/Chemistry

Supervisor

T. Dalpiaz,

Naintenance

Outage Supervisor/Duty

Hanager

G. Kuczynski, Plant Technical

Supervisor

W. Hor rissey,

Radiation Protection Supervisor

'*C. Burke,

Chemistry Supervisor

J. Hettinger,

Chemistry

Foreman

1.2

NRC Personnel

S. Barber,

Senior Resident

Inspector

Other licensee

and contractor

personnel

were also contacted

or interviewed

during the course of this inspection.

denotes

those

personnel

attending

the exit meeting

on September

2,

1989.

2.0

Pur ose

and

Sco

e of Ins ection

This inspection

was

a special

announced

radiological controls

and chemistry

inspection to review the circumstances,

licensee

evaluations

and licensee

corrective actions

associated

with an unplanned

exposure of a contractor

performing reactor water sampling

on August 31,

1989.

The following areas

were reviewed:

circumstances

associated

with the event;

personnel

training and qualifications;

procedure

adequacy

and adherence;

external

and internal

exposure controls;

radioactive

and contaminated

material control;

dose

assessment;

notifications;

and

corrective actions.

The inspector's

evaluation of licensee

performance

in the above

areas

was

based

on inspector interviews with cognizant

personnel

including the

individual who received the unplanned

exposure,

inspector

performance of an

independent

time and motion study,

observations

made during plant tours

and

reviews of applicable documentation.

3.0

3.1

3.2

Descri tion of Event

General

The licensee

hired

a contractor firm to perform

a study of the overall

effectiveness

of the licensee's

liquid radwaste

processing

system.

The majority of this work was being performed in the chemistry laboratory

using existing procedures.

However,

some special

procedures

were being

written to perform certain

sampling activities.

/

,During discussions

of the planned activities

on August 28,

1989,

the

contractor requested

that

a Unit 2 reactor coolant

sample

be collected.

The

sample

was to be analyzed

and the results

used to decide whether the

licensee

would be requested

to participate. in an Electric Power Research

Institute

(EPRI) fuel degradation

study.

The collection of the sample

was

discussed

during

a meeting of chemistry supervisors

and managers

who

authorized

the collection of the sample.

Although the collection of this

sample

was outside the scope of the original contract,

the discussions

regarding the sample did not include the need for special

procedures

to

collect the sample.

Also, expected radiological conditions associated

with

the sampling were not discussed.

~Seci fics

On August 29,

1989 at 4:04 p.m.,

a special

sampling rig was installed in

the Unit 2,

779 ft. chemistry sampling station

fume hood to collect

a

reactor coolant

sample.

The rig, consisting of'

small, approximately 3/4

inch diameter cloth filter medium with P205H reactor water cleanup resin

deposited

on the filter, filter holder,

and associated

tubing was connected

to reactor water cleanup

sample point 223196 located in the

fume hood in

the chemistry sampling station.

An electric

pump controller was located

outside the

fume hood

and

was

used to control

sample flow through the

sample

medium.

The sample

medium was specially designed

to collect

radioactive material

found in reactor

coolant, similar to that removed

by

the reactor water cleanup

system.

The sample

was to be shipped

by the

licensee to

a national laboratory for analysis.

The sampling rig was installed

by a contractor technician

(Individual A)

using routine chemistry radiation work permit

(RWP) number 89-452.

Since

the chemistry sampling station

was locked,

a chemistry technician

(Individual B) accompanied

the contractor.

The rig was installed without

incident.

Protective clothing and whole body and extremity dosimetry

specified

on

RWP 89-452 were worn.

Effluent from the rig was directed to

the fume hood drain which is routed to the radwaste

system.

The'ampler

was set to collect

a sample for 48 hours5.555556e-4 days 0.0133 hours 7.936508e-5 weeks 1.8264e-5 months at

a sample flow rate

of 48

milliliters per minute.

At 12:46 p.m.

'on August 30, the flow rate of the sampler

was checked

and

adjusted

downward.

The Unit 2 chemistry sampling station

was entered

by

the contractor technician (Individual A) and

a chemistry, technician

Individual

C)

who unlocked

and

opened

the door for the contractor.

lthough the sampler

had

been collecting

a reactor coolant

sample for about

21 hours2.430556e-4 days 0.00583 hours 3.472222e-5 weeks 7.9905e-6 months ,

no radiation surveys

were

made

by the contractor technician or

chemistry technician prior to the contractor technician working in front of

the hood containing the reactor coolant sampling rig.

The flow rate

was

adjusted

using the controller outside the fume hood.

The individuals left,

the area after the contractor technician

adjusted

the flow from 48 to 41

milliliters per minute in order to obtain the optimum flow conditions.

At about 2:30 p.m.

on August 31,

1989,

a contractor supervisor

(Individual

D) started

a preplanning

meeting to make arrangements

to remove the filter

from service.

The meeting

was between

the contractor supervisor

(Individual

D) and the contractor technician

(Individual A).

Discussions

were to

include methods to handle

and transport

the sample

from the Unit 2,

779 ft.

chemistry

sample station to the 676 ft. elevation chemistry laboratory

and

anticipated radiological conditions to be encountered.

The contractor

supervisor

(Individual

D) expected

the sample to measure

several

hundred

milliroentgens per hour on contact.

During the briefing, the contractor supervisor

( Individual

D) was

distracted to answer

a telephone call.

Because

the,.reactor

coolant

sample

was to be collected for 48 hours5.555556e-4 days 0.0133 hours 7.936508e-5 weeks 1.8264e-5 months ,

the contractor technician

( Individual A)

believed it was important to retrieve the sample

in a timely manner.

The

contractor technician

went to the chemistry assistant

foreman (Individual

E)

and requested

a chemistry technician to let him into the

779 ft.

chemistry

sample station in order to collect the sample.

The assistant

chemistry foreman provided

a junior chemistry technician (Individual F),

who accompanied

the contractor technician to the

779 ft. Unit 2 chemistry

sample station.

At about 3:00 p.m.

on August 31,

1989,

the junior chemistry technician

opened

the

779 ft. chemistry

sample station

and allowed the contractor

technician

(Individual A) to enter the station.

Although the sampling rig

had collected

a reactor coolant

sample for about

47 hours5.439815e-4 days 0.0131 hours 7.771164e-5 weeks 1.78835e-5 months , neither of the

individuals had

a survey meter to measure

radiation levels emanating

from

the sampler.

The sampling rig was shut off by the contractor technician at

3:06 p.m.

Although the radiation work permit required

use of a lab coat

when sampling

and working with samples,

no lab coats

were worn.

The

contractor technician

wore

a pair of latex gloves to disassemble

the

sampling rig. Cotton glove liners, required

by the radiation work permit

were not worn.

The contractor technician

(Individual A) disassembled

the filter holder

and

dumped, with his left hand,

the ion exchange

resin into a plastic petri

dish.

The contractor technician

used

a pair of tweezers

held in his right

hand to scrape

the medium residue into the petri dish.

The petri dish was

closed

and put on the lip of the

fume hood in close proximity to the

abdomen of the contractor technician.

This operation

was estimated

to have

taken

about

10 seconds.

During the disassembly,

the contractor technician dripped reactor coolant

on his pants.

This was wiped'ff with a cloth.

No frisking was performed

at the sample station.

- The petri dish remained

on the lip of the fume hood for about two minutes

while the sampling rig was put into a plastic

bag held by the chemistry

technician.

The chemistry technician

saw the sample in the petri dish

and

.then could not see it while the rig was being bagged.

The chemistry

technician

believed the contractor technician

put the sample in the

bag with

the rig;

Unknown to the chemistry technician

(Individual F), the contractor

technician ]Individual A) had put the petri dish into the left breast

pocket of his shirt.

The petri dish

was

between

a paper

book of matches

and

a pack of cigarettes.

The matches

were between

the petri dish

and the

individual's chest.

Note: Contact radiation measurements

of the sample

made with an ion chamber.

(RO-2A) at 6:30 p.m on August 31, 1989, indicated

600 millireoentgens

per hour (mR/hr)

gamma radiation

and

16,000 millirads per hour

(mrad/hr)

beta radiation.

Geometry corrections

were not applied to

these

readings.

The individuals left the sample station,

proceeded

down the hall of the

779 ft. elevation of Unit 2, stopped to pick up

a sample of resin,

took the

elevator to the 676 ft. elevation

and proceeded

to the chemistry

laboratory.

The individuals arrived at the chemistry laboratory at about 3: 13 p.m., at

which time the contractor supervisor (Individual D) realized that the

sample

had

been collected without the preplanning

meeting being completed

or

a discussion of the radiological conditions to be encountered.

The contractor supervisor took the petri dish with his left hand

and

measured

the dose rate with an ion chamber

survey meter

(RO-2).

The meter

went off-scale

on the

500 mR/hr scale.

The contractor supervisor

placed

the petri dish in the sample preparation

lab.

The contractor supervisor

held the sample for about

40 seconds.

The contractor supervisor

read the

pocket dosimeter of the contractor technician

(Individual A) and noted it

to read

about

70 mR.

Note:

The exposure of the contractor supervisor will be determined

by the

licensee.

Because

the sample

was held for a short period of time, the

exposure

received is not expected

to be in excess

of NRC limits.

Note: This pocket dosimeter

reading

was most likely the result of the

sample

being in close proximity to the pocket dosimeter.

Because of

sample to dosimeter

geometry considerations,

this dosimeter

may not

represent

the actual

exposure

received.

A detailed

dose evaluation

will be performed

by the licensee.

4.0

5.0

The contractor personnel

did not notify chemistry personnel

but rather

started to clean

up the remainder of their equipment.

The chemistry foreman

(Individual

G) was notified at between

4:30-5:00p.m.

The chemistry foreman

then directed that radiation protection personnel

be notified. The

radiation protection

foreman

( Individual H) was notified at 5:50 p.m.

about

the incident.

The radiation protection

foreman notified radiation protection

management

at 6:40 p.m.

The contractor technician

( Individual A) was interviewed

by

the radiation protection

foreman

( Individual

H) at 6:50 p.m,

on August 31,

1989.

The radiation protection

foreman directed the contractor technician

to enter the whole body friskers at 7: 15 p.m.

The contractor technician's

ants

were found to be contaminated

(200 counts

per minute above

ackground)

and confiscated.

The radiation protection

manager initiated

a dose evaluation.

The

contractor technician's

TLD badges

were

pulled

and the individual was told

that

he could not re-enter the radiologically controlled area.

The

contractor individual left the site at 10:30 p.m.

on August 31,

1989.

8ecause

the contractor

technician

and supervisor

were not told to remain in

the area of the station,

they left the site

on August 31,

1989 to return

home.

After performing

and re-performing dose

assessments

throughout the. night,

the licensee

believed

an exposure

in excess

of 10 CFR 20.403

immediate

reporting limits (150 rem to the skin)

may have occurred.

When the

licensee

realized this at 6:00 a.m.

on September

1,

1989,

the licensee

made

an

Emergency Notification System

(ENS) call to the

NRC at that time.

Notifications

The inspector

reviewed the timeliness of licensee notifications with

respect

to criteria contained

in 10 CFR 20, Standards

for Protection

Against Radiation,

10 CFR 50.72, Notifications,

and Technical

Specifications.

Within the scope of this review no violations were identified.

The

inspector

concluded that the licensee

made appropriate notifications

when

it was determined that

a possible reporting level

may have

been

exceeded.

Dose Assessment

The inspector

reviewed the licensee's

dose

assessment

made for the

contractor technician

(Individual A) who carried the sample in his shirt

pocket

and the dose

assessment

methodology

used.

The inspector's

review

indicated the licensee

was having difficulty determining the dose to the

individual because

of the uncertainties

in the collection efficiencies of

the sampling

medium used.

The sampling

medium had

been fabricated

on site

and

no information was

available regarding its performance.

Also, sample analytical

instrumentation

had not been calibrated for the type of sample collected.

In addition

there was.some

question regarding equilibrium of radionuclides

on the sample

medium and decay of short-lived radionuclides.

As

a result,

the licensee

established

a plan to repeat

sampling of the

reactor coolant under controlled conditions using approved

procedures.

A

national laboratory

was to assist

in analyzing the sample.

Dose

assessment

was to be performed using

a number of state-of-the-art

methods.

The inspector did not have

any concerns

with the licensee's

plans.-

The inspector indicated 'the dose

assessment

for the individuals who handled

or came in close proximity to the sample

was

an unresolved

item

(50-388/89-25-01).

Inspector review of dosimetry records

indicated the contractor technician

(Individual A) who carried the sample in his shirt pocket

had only 12

millirem to the skin of the whole body for the third quarter of 1989 prior

to coming to the licensee's facility.

The contractor

technician received,

based

on pocket dosimeter results,

a total of 81

mR whole body dose during

work activities at the licensee's facility.

As noted in section 3.2, this

included the

70

mR received

when the sample

was collected.

The sample

was

in close proximity to the pocket dosimeter

on the chest

when the sample

was

carried in the shirt pocket.

The contractor technician

was whole body counted prior to leaving the

licensee's facility. No intake of radioactive material

was identified.

The contractor technician

had not performed similiar samplinq at other

stations.

This was the first such

sample collected at the licensee's

facility

6.0

General

Observations

and Conclusions

Within the scope of this inspection the following general

observations

and

conclusions

were

made

by the inspectors.

The following apparent violations were identified:

10 CFR 20.201(b) requires,

in part that each licensee

shall

make or

cause to be made

such surveys

as

may be necessary

and reasonable

to

ensure

compliance with the requirements

of 10 CFR Part 20.

10 CFR 20.201(a)

defines

a survey,

in part,

as

an evaluation of the

radiation hazards

incident to the presence

of radioactive materials

under

a specific set of conditions.

When appropriate,

such

an

evaluation

includes

a physical

survey of material

and equipment

and

measurements

of levels of radiation present.

As discussed

in section

3 above,

the contractor technician

(Individual A) and the chemistry technician (Individual

G) collected

the reactor coolant

sample at 3:06 p.m.

on August 31,

1989. Although

the sampling rig had

been collecting

a reactor coolant

sample for

about

47 hours5.439815e-4 days 0.0131 hours 7.771164e-5 weeks 1.78835e-5 months ,

no radiation surveys

were

made to determine

the

levels of radiation that were present prior to the sampling rig being

disassembled

and the reactor coolant

sample

being handled.

This

sample

was unlike any sample that was previously collected

by the

contractor technician

( Individual A). Such surveys

were necessary

and

reasonable

to ensure

compliance with the extremity, skin and whole

'ody

dose limits of 10 CFR 20. 101.

This is an apparent violation of

10 CFR 20.201(b)

(50-388/89-25-02),

The inspector

noted that

a wall mounted

area radiation monitor was

located

behind the sample station

fume hood. This was

some distance

away and

was inadequate

to inform the .individuals of radiation levels

on the sample.

10 CFR 19. 12 requires,

in part, that all individuals working in or

frequenting

any portion of the restricted

area shall

be kept informed

of radiation in such portions of the restricted

area

and shall

be

instructed

in precautions

or procedures

to minimize exposure.

As discussed

in, section

3 above,

the contractor technician

( Individual A) and the chemistry technician

(Individual

F) collected

the reactor coolant

sample at about 3:06 p.m.

on August 31,

1989.

Prior to their collection of the sample,

the individuals were not

provided

any warning or instructions that the sample

being collected

was

a different type of sample

and would exhibit significant contact

radiation

dose rates.

The individuals were also not provided

any

special

instructions or guidance to minimize their radiation exposure

durinq collection of the sample.

This is

an apparent violation of 10 CFR 19.12.

(50-388/89-25-03).

Technical Specification

6. 11 requires that the lice'nsee establish

and

adhere

to radiation protection procedures.

Radiation Protection

Procedure

AD-00-705, Revision

12, Access

Control

and Radiation

Work

Permit System,

dated

March 16,

1989, states

in section

4. 10, that it

is the responsibility of each radiation worker to understand

and

comply'ith all health physics

access

control

and radiation work

permit

(RWP) requirements.

Signature

on the

RWP signin sheet

indicates

knowledge of the requirements

of the

RWP and of the

radiological conditions in the work area.

RWP No.89-452, Obtain Chemistry Samples,

Analyze Samples

in the Hot

Chemistry

Lab and Perform Sample Preparation

as Necessary,

dated July

31,

1989, required the following:

a lab coat,

surgeons

gloves

and cotton glove liners

when

sampling radioactive

systems

a survey meter to measure

the radiation

dose rate of

samples

and to be used while transporting

samples

measuring

100 mR/hr or greater

a check of the dose rate

on all radioactive

samples prior

to transport

a shielding pig to transport

samples

measuring

100

mR/hour or greater

on the outside of the sample container

constant

health physics

coverage

when transporting

samples

with 100

mR per hour or greater

on the outside of the

sample transport container

As discussed

in section

3 above,

the following was identified when

the contractor technician

( Individual A) and the chemistry technician

( Individual F) collected the reactor coolant

sample at 3:06 p.m.

on

August 31,

1989:

a lab coat

and cotton glove liners were not worn during

sample collection

a survey meter

was not obtained

and used to obtain the

dose rate

on the sample

although the sample container

measured

gr'eater

than

100

mR/hr

on contact

(600 mR/hr),

a shielding pig was not used

to transport

the sample

although the sample

read greater

than

100 mR/hr on contact,

constant

health physics

coverage

was not provided

when

transporting

the sample.

The

above

examples

are

an apparent violation of Technical

Specification

6. 11.

(50-388/89-25-04).

Technical Specification 6.8 requires,

in part, that the procedures

recommended

in Appendix

A of Regulatory

Guide 1.33,

1978,

be

established

and implemented.

Appendix

A of Regulatory

Guide 1.33,

1978,

recommends

in section

10 that chemical

and radiochemical

procedures

be written to prescribe

the nature

and frequency of

sampling

and analyses.

These

procedures

should include laboratory

instructions

and calibration of equipment.

As discussed

in section

3 above,

no procedures

were written to

describe

the

48 hour5.555556e-4 days 0.0133 hours 7.936508e-5 weeks 1.8264e-5 months sampling of the reactor coolant using the resin

impregnated filter medium.

In addition there were

no procedures

for

ca'iibration of the equipment

used.

This is an apparent violation of

Technical Specification 6.8.

(50-388/89-25-05).

10

Other Observations:

Personnel

did not perform personnel

contamination frisking until

returning to the chemistry laboratory.

The radiation work permit

(RWP) used for the reactor coolant

sample

collection was

a routine permit.

The permit did not require

any

surveys to be made prior to handling or working with samples.

The

permit only required

surveys

when transporting

samples.

7.0

Corrective Actions

The licensee

implemented

the following corrective actions following

identification of the unplanned

exposure of the contractor technician.

The keys

used for access

to the chemistry sampling station

were

removed

from chemistry control.

The keys are

now maintained

and

issued

by radiation protection personnel.

The individual who received

the unplanned

exposure

was prohibited

access

to the radiologically controlled area.

The individual who received

the unplanned

exposure

was examined

by a

physician.

No=apparent radiation effects

were noted.

An occurrence

report was initiated.

The licensee

performed

a review of all contractor work groups

on site.

The following matters

were reviewed:

accountability of contractors,

scope of work of contractors,

work controls for contractors,

and

bases

to perform work on site

The licensee

established

a -multi-disciplined task team to review

the event including root causes

and

management

oversight

and control.

The task team

was to develop

recommendations

to prevent recurrence.

The licensee initiated action to obtain outside experts to assist

them in determination of the exposure to the individual who received

the unplanned

exposure.

8.0

~Eit II

The inspectors

met with licensee

representatives

denoted

in Section

1 of

the report

on September

2,

1989.

The inspectors

summarized

the purpose,

scope

and findings of the inspection.

No written material

was provided to

the licensee.

ML17156B363

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