ML17156B429
| ML17156B429 | |
| Person / Time | |
|---|---|
| Site: | Susquehanna  |
| Issue date: | 10/18/1989 |
| From: | Nimitz R, Pasciak W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML17156B428 | List: |
| References | |
| 50-388-89-25-EC, NUDOCS 8911020245 | |
| Download: ML17156B429 (46) | |
See also: IR 05000388/1989025
Text
U.S.
NUCLEAR REGULATORY COMMISSION
REGION I
Report
No.
50-388/89-25
Docket No.
50-388
License
No.
Priority
Category
C
Licensee:
Penns
lvania Power
and Li ht
Com an
2 North Ninth Street
Allentown
Penns
lvania
18101
Facility Name:
Sus
uehanna
Steam Electric Station
Unit 2
Meeting at:
Kin
of Prussia
Penns'vania
Meeting Conducted:
October
3
1989
Prepared
by:
R.
L. Nimitz, Senior
iation Specialist
lo ib
date
Approved by:
W. J.
Pasci
Protection
S
, Chief, Facilities Radiation
ction
at
Meetin
Summar
Enforcement
Conference
held
on October 3,
1989
(NRC Meeting
Report
No. 50-388/89-25)
To ics of Discussion:
The discussions
at the enforcement
conference
covered
the circumstances,
evaluations,
corrective actions,
and apparent violations
associated
with the unplanned
occupational
exposure
of a contractor
employee
at Susquehanna
Unit 2 on August 31,
1989.
The conference
was attended
by NRC and licensee
management
and lasted
about
two hours.
8'Pi 1020245
8'Pi0>+
ADQCK 05000388
6
PNU
DETAILS
Partici ants
Attachment
1 to this meeting report identifies the licensee
and
NRC
personnel
that attended
the Enforcement
Conference.
Introduction
The Enforcement
Conference
was held at the request of NRC Region I to
discuss
the circumstances,
the licensee's
evaluations,
the licensee's
corrective actions,
and the apparent violations associated
with an
August 31,
1989 unplanned
occupational
exposure
of a contractor
employee
which occurred at Susquehanna
Unit 2.
Discussions
NRC Region I management
summarized
the reasons
for holding the
Enforcement
Conference.
The licensee
was requested
to provide the results of his review of the
unplanned
personnel
exposure
event including corrective actions
taken to
prevent recurrence;
In particular,
the licensee
was requested
to
'provide his perception of the findings documented
in
NRC Inspection
Report
No. 50-388/89-25
and whether
he agreed
or disagreed
with the
apparent violations identified
therein'icensee
Presentation
Attachment
2 to this meeting report provides
a
summary of the licensee's
presentation
at the Enforcement
Conference.
The presentation
consisted
of an event timeline, root cause analysis,
summary of the licensee's
dose
assessment
for the involved individual, and
a
summary of an independent
radiological
assessment
of the unplanned
occupational
exposure.
The licensee
stated that
he agreed with the details provided in the
inspection report
and with the apparent violations identified therein.
Concludin
Remarks
Licensee
management
stated that they treated this event
as
a serious
problem and took short
and long term corrective action to prevent
recurrence.
NRC Region I management
acknowledged
the licensee's
corrective actions
taken
and indicated that the licensee
would be informed of the
enforcement
action addressing
the unplanned
occupational
exposure
at
a
later date.
Attachment
1
Enforcement
Conference
Participants
1.
Penns
lvania
Power and Li ht
Com an
S.
H. Cantone,
Manager Nuclear Services
R.
G. Byram, Superintendent
of Plant
Geo. J.
Kuczynski, Plant Technical
Supervisor
Harry L. Rily, HP/Chemistry Supervisor
W.
E. Morrissey, Radiological Protection Supervisor
Richard
L. Doty, Supervisor
Radiation
and Environmental
Services
Dale Roth, Senior Compliance
Engineer
James
M. Kenney,
Licensing Group Supervisor
Charles Kalter, Radiological
Group Supervisor
E. McILuaine,
HP Foreman
F.
S. Gryscavage,
Site Supervisor,
Nuclear Safety Assessment
Group
2.
NRC
M.
R.
Knapp, Director, Division of Radiation Safety
and Safeguards
(DRSS)
R.
R. Bellamy, Chief, Facilities Radiological
Safety
and
Safeguards
Branch
(FRSSB),
DRSS
J.
H. Joyner,
Division Project Manager,
DRSS
J.
C. Linvilie, Projects
Branch
2 Chief
J: DelMedico, NRC/Office of Enforcement
R. J.
Chief, Effluents Radiation Protection
Section
(ERPS),
DRSS
J.
T ~ Furia, Radiation Specialist,
(ERPS)
N. T. McNamara,
Laboratory Assistant,
(ERPS)
R.
K. Christopher,
Enforcement Specialist
W. J.
Pasciak,
Chief, Facilities Radiation Protection
Section
(FRPS)
R.
L. Nimitz, Senior Radiation Specialist,
(FRPS)
G.
S. Barber,
Senior Resident
Inspector
A. Howe, Senior Operations
Engineer
Attachment
2'NFORCEMENT
CONFERENCE
ON
CONTRACTOR UNPLANNED EXPOSURE
OCTOBER 3,
1989
AGENDA
INTRODUCTION AND EVENT TIMELINE
'.G.
BYRAM
ROOT CAUSE ANALYSIS
G.J.
KUCZYNSKI
DOSE
ASSESSMENT
W.E.
MORRISSEY
INDEPENDENT RADIOLOGICAL
ASSESSMENT
R,L.
DOTY
SUMMARY
R.G.
BYRAM
1 of 43
MANAGEMENT PERSPECTIVE
o
RADIOLOGICAL CONSEQUENCES
MINIMAL
o
SERIOUS
NEAR MISS
o
EVENT MANAGED AS SIGNIFICANT
o
ROOT CAUSE ANALYSIS TECHNIQUES SUCCESSFUL
o
BROAD IMPLICATIONS IDENTIFIED AND ANALYZED
o
PROGRAM IMPROVEMENTS ARE ON TARGET
o
DOSE ASSESSMENT UTILIZED STATE-OF-THE-ART
TECHNIQUES.
2of 43
'I
'I
TIME LINE
UNPLANNED EXPOSURE EVENT
AUGUST 31,
$989
8/25/89
CONTRACTORS ARRIVE ON
SITE.
MEET WITH PLANT
PERSONNEL
TO REVIEW
CONTRACTED WORK.
LEAD CONTRACTOR LEARNS
OF ELEVATED OFFGAS
ON
UNIT 2,
REQUESTS
PERMISSION
TO TAKE A
FILTERED. SAMPLE OF
PLANT PERSONNEL
AGREE
THAT CONTRACTOR
OBTAIN SAMPLE.
CONTRACTOR
NEGOTIATING FOR
STUDY.
SAMPLE WOULD BEi
SIMPLE> CONTRACTOR
WOULD DO WORKj OF
SHORT
DURATION.
PAGE
1
OF 6
NO DISCUSSION
OF POTENTIAL
DOSE
RATES,
8/26/89
8/31/89
CONTRACTORS
PERFORM
CONTRACT MORK SCOPE.
8/29/89
APPROX 1600hrs
8/31/89
APPROX 1430hr s
CONTRACTORS INSTALL
TEST
RIG IN UNIT 2
REACTOR BUILDING
SAMPLE STATION.
LEAD CONTRACTOR
MENTIONS TO
CHEM
FOREMAN THE NEED TO
RETRIEVE SAMPLE
TODAY.
CHEM TECH
UNLOCKS DOOR
TO
SAMPLE STATION
48
HOUR COLLECTION
TIME COMPLETE AT
1600hrs
PAGE 2
OF 6
FLIGHT HOME
0700hr s 9/1/89
CHEM FOREMAN ARRANGES
FOR
CHEM TECH
TO
GO
VITH CONTRACTOR AND
OPEN
DOOR
TO SAMPLE
STATION.
APPROX 1430hrs
LEAD CONTRACTOR BEGINS
BRIEF ING SECOND
CONTRACTOR
ON
RETRIEVING SAMPLE.
LEAD CONTRACTOR
INTERRUPTED BY
PHONE CALL.
SECOND
CONTRACTOR
DECIDES
TO
GO
AND
RETRIEVE SAMPLE,
CHEM TECH
TO ACCOMPANY HIM.
LEAD CONTRACTOR
NTENDS
MORE HELP
FROM
PP8 L DUE TO POTENTIAL
DOSE
RATE.
HAS RETRIEVED MANY
LOV DOSE
SAMPLES
OF THIS KIND.
FLIGHT HOME AT
0700hrs 9/1/89
PAGE 3
OF
6
CONTRACTOR
CONTAMINATES PANTS
DURING VORK,
APPROX 1500hrs,
SECOND
CONTRACTOR
AND CHEM TECH
ENTER SAMPLE
STATION. RVP VIOLATED.
SECOND
CONTRACTOR
REMOVES FILTER AND
PLACES IN PLASTIC
PLANCHET, DISASSEMBLES
SAMPLE RIG h PLACES IN
RAD BAG,
PLACES
SAMPLE
PLANCHET IN SHIRT
POCKET.
APPROX 1515hrs
SECOND
CONTRACTOR
AND CHEM TECH
ARRIVE AT CHEM LAB.
o
NO SURVEY METER
o
NO LAB COAT
o
SAMPLE
> 100mr
NOT CONTACTED
NO LEAD PIG
NEEDED HANDS
FREE
TO CARRY BAGS.
RUBBER GLOVE NOT
AVAILABLE.
PAGE 4 OF 6
1630hrs
1800hrs
1830hrs
LEAD CONTRACTOR MEETS
SECOND
CONTRACTOR IN
LAB AND LEARNS HE HAS
RETRIEVED SAMPLE,
CHECKS SAMPLE VITH RO-2.
PEGS
ON 500mR
SCALE.
CHEM FOREMAN, HEALTH
PHYSICS
ASST,
FOREMAN,
h SHIFT SUPERVISOR
NOTIFIED OF HIGH DOSE
RATE SAMPLE
8
UNPLANNED
EXPOSURE,
HP/CHEM
SUPERVISOR
NOTIFIED.
SAMPLE SURVEYED
600mR/hr, 16Rad/hr
INITIAL SKIN DOSE
OF 2,7Rem
CALCULATED.
PAGE 5
OF 6
9/1
0530hrs
0600hrs
9/1
1130hr s
9/1
9/4
CALCULATION SHOVS
SKIN DOSE
GREATER
THAN 150Rem.
ENS NOTIFICATION
MADE TO
NRC.
MANAGEMENT
NOTIFIED.
TASK FORCE
FORMED
TO INVESTIGATE
EVENT AND
DETERMINE
F INAL
DOSE.
TASK FORCE ACTIVITIES
- CONTINUE THROUGH
LABOR DAY VEEKEND.
8/31
2230hr s
9/1
0700hr s
9/1
1600hr s
CONTRACTORS
LEAVE SITE,
RETURN TO
HOTEL,
CONTRACTORS
LEAVE ON
SCHEDULED
FLIGHT HOME.
CONTRACTORS
NOTIFIED OF
POTENTIAL
EXPOSURE,
CONTRACTORS
RETURN TO
ASSIST IN
INVESTIGATIO
AND DOSE
ASSESSMENT.
PAGE 6
OF 6
MANAGEMENT RESPONSE
o
MANAGEMENT NOTIFIED OF EVENT.
8/31
1800
o
HEALTH PHYSICS/CHEMISTRY SUPV
AND RADIOLOGICAL PROTECTION SUPV
ARRIVE ON SITE TO DIRECT EFFORTS.
/
o
MANAGEMENT NOTIFIED OF PRELIMINARY
DOSE ASSESSMENT
EXCEEDING 10CFR20
LIMIT.
8/31
9/1
2000
0530-
0600
o
NRC NOTIFIED OF UNPLANNED EXPOSURE,
9/1
/
0600
o
IMMEDIATE CORRECTIVE ACTIONS TAKEN
KEYS TO SAMPLE STATIONS
RETURNED TO HP.
9/1
'600
REVISED STANDING RWP
FOR
SAMPLING
o
TASK FORCE ESTABLISHED
9/1
1130
OVER 30 PEOPLE
INVOLVED OVER
LABOR DAY.
=
FULL INVOLVEMENT BY BOTH
CONTRACTORS.
o
PPRL
RECEIVES MEDICAL CONSULTATION
9/1
9of 43
NANAGEMENT RESPONSE
(coNT'D)
o
CONTRACTOR RECEIVES NEDICAL SCREENING
9/2
o
PRELININARY TASK FORCE
REPORT
COMPLETE.
o
NANAGENENT BRIEFINGS
o
SHORT TERN ACTIONS IDENTIFIED
o
SHORT TERN ACTIONS COMPLETED
o
,RADIATION ADVISORY COMNITTEE
o
SUSQUEHANNA REVIEW COMNITTEE
o
FINAL LONG .TERN ACTIONS IDENTIFIED
9/0
9/5
9/6
9/8
9/15
9/20
9/27
1600
10 of 43
UNPLANNED EXPOSURE EUENT OE 8/31/89
INVESTIGATIVE TASE TEAM
R,G,
BYRAM
PLANT SUPT
H,L. RILEY
HP/CHEM SUPV
V.E. MORRISSEY
RAD PROTECTION SUPV
R.L. DOTY
RAD/ENVIRON SUPV
G.J.
KUCZYNSKI
TECHNICAL SUPV
FINAL EXPOSURE
CALC
SAMPLE ANALYSIS
RECREATING EVENT
LOCATING CONTRACTOR
MEDICAL SCREENING
EPRI NOTIFICATION
COMPLIANCE
NSAG
NQA
NSG
ROOT
CAUSE
CAUSAL FACTORS
- TIME LINE
MGT. PERSPECTIVE
LESSONS
LEARNED
RECOMMENDATIONS
ENFORCEMENT CONFERENCE
ON
CONTRACTOR UNPLANNED EXPOSURE
OCTOBER 3,
1989
AGENDA
INTRODUCTION AND EVENT TIMELINE
R.G.
BYRAM
ROOT CAUSE ANALYSIS
G.J,
KUCZYNSKI
DOSE
ASSESSMENT
W.E.
MORRISSEY
INDEPENDENT RADIOLOGICAL
ASSESSMENT
R.L,
DOTY
SUMMARY
R.G.
BYRAM
12 of 43
INVESTIGATION TEAM
14
PERSONNEL
o
PLANT TECHNICAL SUPERVISOR
o
SENIOR COMPLIANCE ENGINEER
o
SITE SAFETY ASSESSMENT
GROUP SUPERVISOR
o
3 NUCLEAR SAFETY EVALUATORS
o
3 COMPLIANCE ENGINEERS
o
I SENIOR
NUCLEAR- QUALITY ASSURANCE ANALYST
o
1
NUCLEAR SERVICES
HEALTH PHYSICIST
o
3 TECHNICAL ASSISTANTS/CLERICAL
13 of 43
EVENT ANALYSIS PROCESS
DOCUMENT
SEARCHES
TIMELINES
INTERVIEWS
PROCEDURE
REVIEWS
EVENT AND CAUSAL FACTORS
CAUSE AND EFFECT
ANAGEMENT
INTERACTION
AND
ANALYSIS
PREVIOUS EVENTS
EVALUATED
BARRIER ANALYSIS
CAUSE AND EFFECT ANALYSIS
CONTRACTOR UNPLANNED EXPOSURE
OF 8/3P/89
PAGE
1
OF 5
NO HP COVERAGE
PROVIDED
NO SURVEY
EQUIPMENT
USED ~
NO NEED F'R
(GO TD PAGE 2)
SAMPLE EXCEEDING RVP
OF 100nR/hr
NOT KNOVN
RVP REQUIREMENT
TO
SURVEY SAHPLE VIOLATED
HANDS FULL,
RUBBER GLOVE HE
VOULD NORMALLY
PLACE A SAHPLE
IN NOT AVAILABLE
ND ALARMING
DOSIMETRY
PROVIDED
NDT NORMAL
PRACTICE TO
SUPPLY ALARHING
DOSIMETRY
CONTRACTOR
RECEIVES
UNPLANNED
EXPOSURE
CONTRACTOR PUTS
HIGHLY RADIO- .
ACTIVE SAMPLE
IN SHIRT POCKET.
CONTRACTOR NOT
AVARE SAMPLE
VAS HIGMLY
RADIOACTIVE
SAMPLE
NFVER
SURVEYED
ND PRE-JDB
BRIEFING
HELD
(GO TO PAGE 3)
CHEH TECH NOT
AVARE SAMPLE
VAS HIGHLY
RADIOACTIVE
NO EXPERKNCE
VITH THIS
TYPE OF
SAHPLE.
(GO TO PAGE 4)
NO SPECIF'IC
PROCEDURE
USED
(GO TO PAGE 5)
NO VORK CONTROL
DOCUMENT
USED
NO ROUTINE
VORK DOCUMENT
USED
BY
CHEMISTRY
SAMPLE
EXCEEDING RWP
TRIGGER
OF
100 mR/hr
NOT
KNOWN
SAMPLE ACTIVITY
NQT COMMUNICATED
FROM LEAD CON-
TRACTOR TO PP8L
SECOND
CONTR.
CAUSE AND EFFECT ANALYSIS
CONTRACTOR UNPLANNED EXPOSURE
OF 8/31//89
PAGE 2 OF 5
NO NEED FOR
KEYS FOR
SAMPLE.
STATION IN
THE LAB
RAD KEY
DELEGATION
FROM HP
TO
CHEM
SECOND
CONTRACTOR
RETRIEVED
NUMEROUS SAMPLES
IN PAST (HOWEVER
ALL WERE LOW
ACTIVITY SAMPLES)
CHEM ROUTINELY
L FREQUENTLY
REQUIRES
ACCESS
TO
SAMPLE STATIONS
CHEM TECHs
RECEIVE
TRAINING ON
RADIOLOGICAL
PRACTICES.
WORK PERCEIVED
AS ROUTINE BY
SECOND
CONTR.
AND CHEM TECH.
SAMPLE ACTIVITY
NOT COMMUNICATED
FROM LEAD CONTR,
TO SECOND
CONTR.
GO TO
'NO BRIEFING'
CHEM TECH IS NOT
PROPERLY
BRIEFED
ON CONDITION QF
SAMPLE ONLY
INSTRUCTED TO
GO TO
'NO BRIEFING
CONTRACTOR
SECOND
CONTRACTOR
ASSUHES
THIS
SAHPLE
NO
DIFFERENT THAN
OTHERS L LEAVES.
GO
TO
'NO EXPERIENCE'AUSE
AND EFFECT ANAIYSIS
CONTRACTOR UNPLANNED EXPOSURE
OF 8/31/'89
PACE 3 OF 5
PHONE CALL
DIVERTS LEAD
CONTRACTOR FROM
BRIEFING
NO PRE-JOB
BRIEFING
HELD,
HE DIDN'T VANT
THE CONTRACTOR
TO BE HIS
RESPONSIBILITY
POOR
PERF'ORMANCE
BY CONTRACTOR
IN 1986
CONTRACTOR
COORDINATION
VAS VIA CHEM
FOREHAN (FORM-
ERLY RAD OPS
FOREMAN) FOR
RAD OPS
PURPOSES.
CHEN TECH
ASST. FOREHAN
DIDN'T PROVIDE
A BRIEFING
HE BELIEVED
HE VAS ONLY
PROVIDING
SUPPORT
HE DIDN'T THINK
THE CONTRACTOR
VAS HIS
RESPONSIBILITY
HE BELIEVED
OPERATIONS HAD
RESPONSIBILITY
HE BELIEVED IT
MAS A
RADVASTE PROJ.
NOT CHEHISTRY'S
PURPOSE
OF
CONTRACT VAS
IDENTIFIED AS
RADVASTE
F'ILTER
OPTIMIZATION
PREVIOUS
CONTRACT WORK
IN 1986 VAS
COORDINATED BY
RAD-OPS
CAUSE AND EFFECT ANALYSIS
CONTRACTOR UNPLANNED EXPOSURE
OF 8/31/89
PAGE 4
OF 5
CONTRACTOR
NLY EXPERIENCE
HAD BEEN VITH
LOV LEVEL
LRV SAMPLES
LIMITED NUCLEAR
BACKGROUND,
APPROX 3 YEARS
NO EXPERIENCE
VITH THIS
TYPE OF
SAMPLE
TECHNIQUES
NEVLY
DEVELOPED BY
CONTRACTOR FOR
VORK
CHEM TECH
NOT
A ROUTINE
SAMPLING
TECHNIQUE AT
NO NEED FOR
ROUTINE
SAMPLING OF
THIS KIND
CAUSE AND EFFECT ANALYSIS
CONTRACTOR UNPLANNED EXPOSURE
OF 8/31/89
PAGE 5 OF 5
VERY SIMPLE
MOULD ONLY
BE IN A
SHORT
TIME
LESS
THAN
ADEQUATE
COMMUNICATION
BY CONTRACTOR
NO SPECIFIC
PROCEDURE
USED
NEED FOR
SPECIFIC
PROCEDURE
NOT REVIEMED.
HIGH RADIATION
POTENTIAL NOT
RECOGNIZED
NO IMPACT TO
PLANT
LESS
THAN
ADEQUATE
REVIEV BY
PPS L
LAST MINUTE
ADDITION TO
SCOPE
OF
CONTRACTOR
YORK
UNPLANNED EXPOSURE ANALYSIS
CONTRACTOR CONTROL
CONTRACTOR CONTROL
COMMUNICATIONS
o
OWNERSHIP
o
RESPONSIBILITIES
o
WORK CONTROL
WORK CONTROL
MANAGEMENT
INTERACTION
AND
ANALYSIS
BROAD
IMPLICATIONS
PURSUED
RADIOLOGICAL CONTROL
RADIOLOGICAL CONTROL
PROCEDURE
ADHERENCE
o
STANDING RWP's
o
LOCKED DOORS
o
CHEMISTRY PRACTICES
CONTRACTOR CONTROL
o
ALL CONTRACTORS IDENTIFIED.
1,000
PEOPLE
100 FIRMS
o
ACCOUNTABLE OWNERSHIP IDENTIFIED.
o
SCOPE
OF
WORK AND METHOD OF
CONTROL
DEFINED.
o
PERFORNANCE BY EACH CONTRACTOR TO SSES
STANDARDS ASSESSED.
21 of 43
CONTRACTOR CONTROL
WHAT WE LEARNED
0
SUSQUEHANNA HAS EFFECTIVE CONTROL OF
OUR CONTRACTORS.
SEVERAL EXCEPTIONS
WERE NOTED:
SMALL.FIRMS
SPECIALIZED TECHNICAL FOCUS
RECOGNIZED EXPERTISE
SEVERAL SMALL CONTRACTORS
HAD NO CLEAR OWNERS
AND METHOD OF
CONTROL.
ANII
DER/BRP
8 CHEMISTRY CONTRACTORS
CONFIGURATION CONTROL CONTRACTOR
0
SUSQUEHANNA HAS
A WELL DEFINED CONTRACTOR
CONTROL
PROGRAM
POLICIES, NDI,
PROCEDURES
IN PLACE
EMPHASIS
ON COMMERCIAL ASPECTS
NEED TO EMPHASIZE FIELD MANAGEMENT CONTROL.
22 of 43
RADIOLOGICAL CONTROLS
o
ALL 23 STANDING RWP's
EVALUATED
SCOPE
OF
WORK ASSESSED
CLARITY OF REQUIREMENTS REVIEWED
COMPLIANCE ASSESSED
BY LINE MANAGEMENT
o
RADIATION AREA (<100 MR/HR) KEY CONTROL EVALUATED
ONLY CHEMISTRY AND OPERATIONS
HAD DELEGATED KEYS
ASSESSED
LEVEL OF UNDERSTANDING AND COMPl IANCE
WITH RWP's.
o
RADIOLOGICAL PRACTICES
BY CHEMISTRY TECHNICIANS
ASSESSED.
TRAINING
COMPLIANCE
ADEQUACY OF CONTROLS
23 of 03
-. RADIOLOGICAL CONTROLS
WHAT WE LEARNED
o
SUSQUEHANNA HAS AN EXCELLENT KEY CONTROL
PROGRAM.
AN EXCEPTION WAS FOUND WITH CHEMISTRY.
CONTROL WITHIN OPERATIONS IS EXCELLENT.
o
SUSQUEHANNA STANDING RWP's
ARE EFFECTIVE.
AN EXCEPTION
WAS FOUND WITH THE CHEMISTRY RWP.
A RESULT OF WORKER INPUT, WRITTEN INSTRUCTIONS
WERE ENHANCED TO ASSURE CLARITY.
o
RADIOLOGICAL CONTROL
PROGRAM FOR CHEMISTRY IS
EFFECTIVE.
CHEMISTRY TRAINING PROGRAM REQUIRES ACCELERATION.
CHEMISTRY TECH INVOLVED WAS NOT TRAINED.
FIVE NEW CHEM TECHS REQUIRE INITIALTRAINING.
24 of 43
ACTION PLANS
STATUS
DATE
o
RETURN KEYS FOR SAMPLE STATION
TO HEALTH PHYSICS.
COMPLETE
9/I/89
o
LIMIT SCOPE
OF
RWP 89-052.
o
PERFORM
THOROUGH INVESTIGATION AND
ANALYSIS OF EVENT.
o
IDENTIFY BROAD ISSUES.
o
IDENTIFY ALL SITE CONTRACTORS.
o
ASSESS
CONTROL AND PERFORMANCE OF
EACH CONTRACTOR.
COMPf ETE
9/1/89
COMPLETE
9/0/89
COMPLETED 9/6/89
COMPLETED 9/6/89
COMPLETED 9/8/89
o
ASSESS
SCOPE
AND CLARITY OF
STANDING RWP's.
COMPLETED 9/25/89
o
ASSESS
COMPLIANCE TO STANDING RWP's.
COMPLETED 9/25/89
o
DETERMINE GROUPS
DELEGATED KEYS.
o
EVALUATE CONTROL
ON DELEGATED KEYS
o
ASSESS
RADIOLOGICAL PRACTICES BY
CHEMISTRY.
COMPLETED 9/6/89
COMPLETED 9/22189
COMPLETED 9/27/89
25 of 43
ACTION PLANS (coNT'D)
o
ASSIGN CLEAR OWNERSHIP
TO ALL
CONTRACTORS.
COMPLETED 9/8/89
o
STOPPED
WORK FOR SEVERAL CONTRACTORS
COMPLETED 9/5/89
WITH INADEQUATE SITE CONTROL.
o
REVISE ANY STANDING RWP's
THAT LACK
CLARITY.
COMPLETED 10/1/89
o
TRAIN FIVE CHEMISTRY TECHNICIANS THAT
TO
GO
HAVE NOT HAD RADIOLOGICAL PRACTICES
TRAINING.
12/1/89
o
DEVELOP STATION ADMINISTRATIVE
PROCEDURE
ON
CONTRACTOR CONTROL,
o
TRAIN STATION PERSONNEL
ON
NEW
CONTRACTOR CONTROL PROCEDURE.
TO
GO
12/31/89
TO
GO
3/31/90
o
DETERMINE NEED FOR RETRAINING
FREQUENCY OF
CHEM TECHNICIANS ON
RADIOLOGICAL PRACTICES.
COMPLETED 10/2/89
o
DEFINE KEY DELEGATION IN HEALTH
PHYSICS
ADMINISTRATIVE PROCEDURE.
TO
GO
12/15/89
26 of 43
SUMMARY
o
WORK CONTROL AT SUSQUEHANNA IS EXCELLENT.
CONTRACTOR CONTROL ENHANCEMENTS WILL ENSURE
CONSISTENCY FOR THE LIFE OF THE PLANT.
o
OUR RADIOLOGICAL CONTROL
PROGRAM REMAINS STRONG,
CHEMISTRY TRAINING PROGRAM REQUIRES
ACCELERATION
o
FINDINGS CONFIRM THAT OUR CHEMISTRY ENHANCEMENTS
ARE ON TARGET.
27 of 43
ENFORCEMENT CONFERENCE
ON
CONTRACTOR UNPLANNED EXPOSURE
OCTOBER 3,
1989
AGENDA
INTRODUCTION AND EVENT TIMELINE
R.G.
BYRAM
ROOT CAUSE ANALYSIS
G.J.
KUCZYNSKI
DOSE
ASSESSMENT
W.E.
MORRISSEY
INDEPENDENT RADIOLOGICAL
ASSESSMENT
R.L.
DOTY
SUMMARY
R,G,
BYRAM
28 of 43
DOSE
ASSESSMENT
TEAM
12
PERSONNEL
RADIOLOGICAL PROTECTION SUPERVISOR
PLANT STAFF
RADIOLOGICAL GROUP SUPERVISOR
GENERAL OFFICE
HEALTH PHYSICIST PLANT 'STAFF
HEALTH PHYSICIST
GENERAL OFFICE
HEALTH PHYSICIST GENERAL OFFICE
HEALTH PHYSICS SPECIALIST I I
PLANT STAFF
SENIOR
SC IENTIST-CHEMISTRY GENERAL OFFICE
BATTELLE
o
2 SENIOR
RESEARCH SCIENTIST
o
SENIOR TECHNICAL SPECIALIST
2
CONTRACTORS
29 of 43
. GEOMETRY
SOURCE
STRENGTH
EXPOSURE
TIME
DOSE
30 of 43
GEOMETRY.
2
CN DIAB
RESIN
CAKE
e.<e
oc
5OURCE
(INSOLUBLE)
SOURCE
(SOLUBLE)
DRSTRIBUTEB
- .
- ;.:.:;".;;;:::::::.:::::::.'
FILTEa CLOTH
.83
Paar DISH,ig g.
Are GAr
.64
NATCH PAPER .86
(
t DOUBLE THICK.
5KIN .887 m
31 of 43
DOSE ASSIGNMENT
SOURCE
STRENGTH:
o
REPRODUCED
AND MEASURED TWO REPLICATE COOLANT SAMPLES.
o
DETERMINED THE ACTIVITY
o
IDENTIFIED THE ISOTOPES
HALF LIFE
PURE BETA EMITTERS
GEOMETRY:
o
DETERMINED THE ATTENUATORS
SHIRT
PLANCHET
MATCHES
RESIN
o
MEASURED EFFECTIVENESS
OF ATTENUATORS ON
REPRODUCED
SAMPLES'XPOSURE
TIME
o
DETERMINED DURATION IN POCKET.
o
IDENTIFIED OTHER HANDLING.
ASSIGNMENT
o
ASSIGNMENT IS:
3.0
REM SKIN
070
MR MHOLE BODY
< 100
MR EXTREMITY
o
PENDING BATTELLE FINAL REPORT.
32 of 43
HEALTH PI.BASICS DOSE ASSESSMENT PLAN
"SUNDAY
MONDAY
9 /i
TUESDAY
e /s
WEDNES DAY
TFIURSDAY
FRIDAY
9 /8
SATURDAY
FHOCEDUH1U
1
PEREQRM MOCK UP TRAINING
PREPARE
FOR SAMPUNG
WITH CHEMISTRY SAMPUNG TEAM
I
I
POIIC
I
I
I
I
I
DEVELOP RADIOMCICALCONmOLS iQR BATELLE ANALYSIS
SAMPLES
SAMPLE A
UNlT II 48 IIOUR
BATH<"LLE
SECURE EQUIPMENT
SAMPLE B
UNIT II 48 IIOUR
I
I-
MEASURE
I
MEASURE
SAMHZ A
SAMPLE B
CONFERENCE
0-W
CALL
PERSONNEL ONSfK
DOSE ASSESSMENT
DEVHDP TIMEUNE
I
I
DEIKRMINE
/
PRECISE CEOMLTRY
J
0
REVISE PRELIMINARY
APP
E
DATE
HNAUZE DOSE
ASSESSMENP
DOSE CALCULATION BASIS
INITIAL
CURRENT
EXPOSURE
o
10 MINUTE CONSERVATIVE
ASSUMPTION
o
6.5 MINUTES BASED
ON
TIME MOTION RE-ENACTMENT
CAPTURED
ON VIDEO TAPE.
GEOMETRY
o
SHIRT AND PLANCHET
ONLY ATTENUATORS
o
-DEFINITIVE GEOMETRY
ESTABLISHED, WHICH
IDENTIFIED RESIN
AND
MATCHBOOK AS SIGNIFICANT
ADDITIONAL ATTENUATORS.
SOURCE
STRENGTH
o
REACTOR COOLANT ACTIVITY
WITH NO EQUILIBRIUM
ASSUMED.
o
QUANTIFIED SOURCE
TERM
BASED
ON REPLICATE SAMPLE
MEASUREMENTS AND RADIO-
CHEMISTRY DATA ANALYSIS.
o
SMALL SAMPLE (lms)
ASSUMED
REPRESENTATIVE OF ENTIRE
MASS (1600 Ms) .
34 of 43
CONCLUSIONS
OF
DOSE ASSESSMENT
TEAM ACTIVITIES
o
RE-ENACTMENT, REPLICATE SAMPLING, AND INDEPENDENT ANALYSIS
HAVE PROVIDED ACCURATE DOSE ASSIGNMENT.
o
ONLY TWO INDIVIDUALS REQUIRED SPECIAL DOSE
ASSESSMENT
TECHNIQUE.
o
ALL OTHER INDIVIDUALS RECEIVED ( I NREN.
o
CURRENT PPaL
DOSE ESTIMATES AND BATTELLE'S INDEPENDENT
EVALUATION ARE IN GOOD AGREEMENT.
PPaL
BATTELLE
WHOLE BODY
200
070
SKIN
3
3.0
EXTREMITY
(IOO NREN
Q IOO MREM
o
ESTIMATED COMPLETION DATE:
10/31/89.
35 of 43
ENFORCEMENT CONFERENCE
ON
CONTRACTOR UNPLANNED EXPOSURE
OCTOBER 3,
1989
AGENDA
INTRODUCTION AND EVENT TIMELINE
R.G.
BYRAM
ROOT CAUSE ANALYSIS
G.J.
KUCZYNSKI
DOSE ASSESSMENT
W.E.
MORRISSEY
INDEPENDENT RADIOLOGICAL
ASSESSMENT
R.L.
DOTY
SUMMARY
R.G.
BYRAM
36 nf 43
INDEPENDENT RADIOLOGICAL ASSESSMENT
OF
RESPONSE
TO UNPLANNED EXPOSURE
INCIDENT
37 nf 43
IMMEDIATE RESPONSE NEEDS
PLANT HEALTH PHYSICS
o
ENSURE
CONTROL OF
SOURCE
o
EVALUATE POTENTIAL FOR
PERSONNEL
CONTAMINATION/UPTAKE
o
INITIATE INVESTIGATIVE PROCESS
o
TAKE INITIALACTIONS TO MINIMIZE POTENTIAL FOR
RECURRENCE
o
ESTIMATE DOSE
o
MAKE APPROPRIATE NOTIFICATIONS TO
REGULATOR
(AND OTHERS)
o
REQUEST MEDICAL EVALUATION
38 of 43
ACTUAL RESPONSE
o
SOURCE
WAS CONTROLLED
SHIELDED)
LOW OCCUPANCY AREA
"LOCK AND KEY" CONTROL
o
INDIVIDUALSWERE "FRISKED"
SECOND
CONTRACTOR:
LEAD CONTRACTOR:
CHEMISTRY TECH:
PCM AND WHOLE BODY COUNT
PCM
o
INVESTIGATIVE PROCESS
WAS BEGUN
INTERVIEWS INITIATED
CALLS MADE TO OPERATIONS
AND HEALTH PHYSICS
SUPERVISORY
PERSONNEL
II
o
CORRECTIVE ACTION PROCESS
WAS BEGUN
DISCUSSIONS
WITH CHEMISTRY PERSONNEL
KEY CONTROL CHANGES
CHANGES
o
DOSE DETERMINATION PROCESS
BEGAN
ESTIMATES BASED ON SURVEY RESULTS
ESTIMATES BASED ON SAMPLE ANALYSES
o
NRC WAS NOTIFIED WHEN POTENTIAL FOR DOSE
0 150
REM CALCULATED
o
MEDICAL EVALUATION WAS REQUESTED
39 of 43
ASSESSMENT
OF
RESPONSE
o
IMMEDIATE NEEDS
WERE MET
o
MANAGEMENT WAS INVOLVED
o
RESPONSE
CAN ALWAYS BE BETTER
RESPONSE
CHECKLIST
DOSE ESTIMATION
40 of 43
RESPONSE
CHECKLIST
o
PREDEFINED
COMMUNICATIONS PLAN
UNPLANNED VS.
OVEREXPOSURE TERMINOLOGY
EXPECTATIONS PP&L,
PERSONNEL
o
RESOURCE MOBILIZATION
AFFECTED DISCIPLINES
CRITICAL EVALUATORS
o
NON-RADIOLOG ICAL ISSUES
FITNESS
FOR DUTY RULES
MEDICAL EVALUATIONS
41 of 43
I
DOSE ESTIMATION ENHANCEMENT
o
RESOURCE MOBIlIZATION
o
PREDEFINED
COMMUNICATIONS PLAN
o
GEOMETRY CORRECTION
FACTORS
o
ANALYSES FOR HIGH-ACTIVITYSOLID SAMPLES
o
SOFTWARE AVAILABILITY
42 of 43
KEY ENHANCEMENT ACTIONS
o
DEVELOP RESPONSE
CHECKLIST
o
MODIFY HP-TP
FOR
GEOMETRY CORRECTION
o
DEVELOP ALTERNATIVE COUNTING GEOMETRIES
NOTE'ROCEDURAL
ENHANCEMENTS
RESOLVABLE IN REASONABLE TIMEFRAME
43 of 43