ML17216A514
| ML17216A514 | |
| Person / Time | |
|---|---|
| Site: | Saint Lucie  |
| Issue date: | 03/25/1986 |
| From: | Hosey C, Weddington R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| To: | |
| Shared Package | |
| ML17216A512 | List: |
| References | |
| 50-335-86-01, 50-335-86-1, NUDOCS 8605050569 | |
| Download: ML17216A514 (23) | |
See also: IR 05000335/1986001
Text
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UNITED STATES
NUCLEAR REGULATORY COMMISSION
REGION 11
101 MARIETTASTREET, N.IN.
ATLANTA,GEORGIA 30323
Report No.:
50-335/86-01
Licensee:
Florida Power
and Light Company
9250 West Flagler Street
Miami,
FL
33102
Docket No.:
50-335
Facility Name:
St.
Lucie
1
License No.:
Inspector:
R.
E
'on
.W,
d1
Approved by:
C.
M.
Ho
y,
Sec
on Chief
Division of Radi
ion Safety
and Safeguards
Inspection
Conducted:
January 8-9,
and February 25-26,
1986
l ~
Date Signed
3 ~d'<
Date Signed
SUMMARY
t
Scope:
This special,
announced
inspection entailed
11 inspector-hours
onsite in
the area of a potential
whole body radiation exposure
in excess
limits.
Results:
Two violations were'dentified:
failure to establish
radiation
protection procedures
and to perform adequate
evaluations.
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REPORT
DETAILS
1.
Persons
Contacted
Licensee
Employees
"D. A. Sager,
Plant Manager
"H. F. Buchanan,
Health Physics Supervisor
K. Payne,
Health Physics
Engineer
R. McCullers, Health Physics
Operations
Supervisor
J.
R. Smith, Radiation Protection
Man
"J.
L. Danek,
Corporate
Health Physicist
NRC Resident
Inspectors
- R. Crlenjak, Senior Resident
Inspector
- H. Bibb, Resident
Inspector
- Attended exit interview
2.
Exit Interview
The inspectio n
scope
and findings were discussed
on January
9,
1986, with
those
persons
indicated
in Paragraph
1
above.
The
issue
concerning
the
potential
whole
body
exposure
in
excess
of
10 CFR Part 20 limits was
designated
an
Unresolved
Item* pending
Region II review of the licensee's
final
internal
investigation
report,
which'
licensee
representative
committed to forward to Region II by January
31,
1986.
The failure of the
licensee
to establish
a radiation control procedure for the
work and fai lure to adequately
evaluate
dosimetry
data
was also discussed.
The licensee
acknowledged
the inspection
findings
and took
no exceptions.
The licensee
did not identify as proprietary
any of the materials
provided
to or reviewed
by the inspector during this inspection.
During
a
telephone
conversation
on March 13,
1986,
between
the St.
Lucie
Site Vice Presiden't
and the Chief, Projects
Section
2C,
the
licensee
was
informed that the Unresolved
Item had been
determined to be
a violation of
NRC
requirements
in that
the
licensee
failed
to
perform
an
adequate
evaluation of personnel
whole body exposures.
"An Unresolved
Item is
a matter
about which more information is required to
determine
whether it is acceptable
or,may involve a violation or deviation.
Investigation of Potential
(93702)
During November
and
December
1984, the licensee
performed
sludge
lancing of
the Unit
The sludge lancing work was accomplished
by
a
worker placing his hand
and
arm through either of the
two steam
generator
hand
holes
(one
on the cold leg side
and
one
on the hot leg side) while
standing
on
a platform.
The licensee initiated radiation work permit
(RWP)
number
1417 for the work.
The
RWP required that the worker be provided with
extremity dosimetry
(TLD and pocket dosimeter)
on both wrists
and that the
worker's
assigned
whole body thermoluminescent
dosimeter
(TLD) and
normal
plant dosimeter
(0-500
mi llirem) be relocated
to the whole
body location
expected
to receive
the highest
dose.
Additionally, a 0-1500
mi llirem and
0-5000
mi llirem dosimeter
was also required to be worn in the
same location
as
the
TLD.
The
TLD and
three
dosimeters
were
placed in
a plastic
bag
before the worker entered
containment.
A worker assigned
to perform sludge lancing was required to sign in on the
applicable
RWP at the
containment
access
control point.
His time of entry
and dose
on his assigned
dosimeter
were recorded
on the
RWP sign-in sheet.
The worker was
given
a form before entering
the containment titled "High
Radiation
Area Entry Authorization" (referred to
as
a "jump sheet")
which
included
the total time permitted
in the
steam
generator
and the
maximum
dose that
he could receive.
After entering
containment,
the
worker
reported
to the
health
physics
technician
providing coverage
for the job and presented
him with his "jump
sheet."
The health physics technician
would determine
which arm the worker
was going to place in the
and would relocate
the plastic
bag
containing the whole body TLD and three dosimeters
to that arm.
The bag
was
taped to the outside of the arm above the elbow.
A licensee
representative
stated
that
the
dosimetry
was typically arranged
so
that
the
three
dosimeters
were parallel to each other
and the arm.
The TLD, a two element
Harshaw
badge,
was oriented
so that the attenuated
or shielded
chip
was
closest to the elbow.
When the worker was
ready to enter the
the health physics
technician
would start
a
stopwatch
to
measure
the
elapsed
time in the
generator.
Workers
would
frequently
make
several
"jumps"
while
in
containment
in order to move to another
handhole
location or to work the
equipment.
The health physics technician maintained
a cumulative record of
his time in the
steam
generator
and required
the worker to leave
when the
total
was at or near
the designated
stay time
on the
"jump sheet."
The
worker'
pocket dosimeter
was
read at the control point
as
he exited the
containment
and his time of exit and dose
were recorded
on the
RWP sign-in
sheet.
On
December
3,
1985,
a worker exited
containment
and
the control
point
technician
observed
that
he
had
a
dose of 860 millirem indicated
on his
pocket dosimeter.
The health physics technician
observed that the worker's
jump
sheet"
indicated
that
his
allowable
remaining
exposure
was
670
mi llirem
and
his
allowance
for that
particular
entry
had
been
565 millirem.
The health
physics
supervisor
was notified and
he directed
that the worker's
TLD be read.
The
worker's
was
read
that
afternoon
and it indicated
a
dose
of
2084
mi llirem
on
element
1
(unshielded)
and
2667 millirem
on
element
2
(shielded).
His
TLD had
been
read previously at the end of November
1985,
but the readings
had
not
been
posted
to his records
at the time of the
event.
The November
1985
TLD reading
had been
334 milli rem
on element
1 and
352 mi llirem on element
2.
The whole
body dose
was normally determined
by
the shielded
TLD element
and
the unshielded
element
was
used
to determine
skin exposure.
Therefore,
his total
exposure
for the quarter
by TLD was
2768 millirem to the
skin
and
3019 millirem to the whole body.
The whole
body exposure
recorded
by the
TLD was therefore in excess
of the whole body
exposure limit stated
in 10 CFR 20. 101 of 3000
mi llirem per calendar quarter.
The
licensee
initiated
an
investigation.
The
TLD response
and
proper
operation
of TLD reader
were
checked
and verified to
be within specified
limits.
A source
response
check
was also
performed
on all the 0-1000
and
0-5000
mi llirem pocket dosimeters
that
had been
used for sludge
lancing
and
they all responded within an acceptable
+12 percent of the expected
value.
The licensee
concluded,
based
on radiation
surveys that
had been
performed
in the handhole
on October 30,
1985, that the worker's
arm had been
exposed
in a non-uniform radiation field with a dose gradient of approximately
1 to
3 rem/hour per inch increase
as the
arm went further into the
steam genera-
tor.
The licensee
also
conducted
tests
with TLDs in the
steam
generator
handhole
and in a radiac calibrator.
The TLDs exposed
in the handhole
were
placed
inside
a plastic
bag
along with three
dosimeters
and
were
mounted
on
a
45
wooden
wedge affixed to
a
2"
x 4" length of wood.
The
shielded
element of the TLD, which was closest to the source,
read
10 to
19
percent
higher in
18 out of the
20 trials.
The
TLDs tested
in the radiac
calibrator were placed
90~ to the plane of the
source
and overresponded
only
an
average
of
3 percent.
From this,
the licensee
concluded
that the
would accurately
measure
the
exposure 'in
a uniform field such
as
in the
radiac calibrator;
however, further assessment
was warranted
when exposures
occur in non-uniform radiation fields.
The licensee
reviewed all of the radiation work permit timesheets
and "jump
sheets"
to reconstruct
the activities of the worker.
The contract
worker
had been at the licensee's
site during the period October
31 to November 7,
1985,
in order to complete
general
employee training
and returned
to the
site at the
end of November
1985,
to participate
in the
steam
generator
work.
The following tables
summarize
the exposure
data
by pocket dosimeter
for the
dates
when
"jump sheets"
were
prepared
for the
worker
and
the
results of his extremity and whole body TLD readings:
Dosimeter
Readin
s
Date
Time in
Generator
~Sec
Number
of Arm
Entries
Rt. Wrist
Lt. Wrist
W~hole Bod
11/28
11/29
11/30
12/01
12/02
12/03
No Entry
No Entry
122
No Entry
645
330
1097
6
10
4
100
100
0
50
3800
50
4100
120
100
1000
50
200
250
1720
80
135
110
150
1000
860
2335
TLD Readin
s
Date
11/30
12/03
Quarter Total
Rt. Wrist
406
4215
4621
Lt. Wrist
948
2434
3382
Skin
~Element
Q1
334
2088
2418
Whole Body
LEE2
352
2667
3019
At the time of the inspection,
licensee
representatives
stated that their
evaluation of the event
was not yet complete;
however,
they believed that
no
exposure
in excess
of 10 CFR Part 20 limits had occurred.
The first reason
given by the licensee
was the IE Information Notice 83-59,
Dose Assignment
for Workers in Non-Uniform Radiation Fields, which stated that each
arm can
receive
a dose
up to the applicable regulatory limit.
Since the worker had
alternated
arms placed in the
no one
arm likely received
an
exposure
in excess
of 3000 millirem.
A similar exposure
event that occurred
at another nuclear
power facility was cited as another
reason
to support the
position that
no excessive
exposure
had occurred.
In that exposure
event,
the licensee
had averaged
the values
on the
TLD elements
to obtain the
integrated
dose to the blood forming organ,
the red marrow in the
bone
(humerus) of the upper arm, which was the portion of the whole body that
received the exposure.
They maintained that just using the value from one
TLD element
was not an appropriate
measure
of the exposure
the organ
had
received
since the radiation field had not been uniform.
Averaging the
values
on the two TLD elements
in this exposure
event would also result in
an exposure
less
than
10 CFR Part 20 limits.
The licensee
stated that they
would complete their evaluation
and provide
a copy of their internal
investigation report to Region II by January
31,
1986.
Review of the
licensee's
investigation report was identified as
an Unresolved
Item.
The inspector
noted that
on December
12,
1985, the worker had received
a
whole body exposure of 860 mi llirem as indicated
by pocket dosimeter for the
four steam generator
arm entries,
which was
52 percent higher than the
t
~
'I
t
administrative
exposure limit for that day written on his "jump sheet" of
.565 millirem.
The exposure
received
on his last entry gave the worker
a
total exposure for the calendar quarter'f
2335 millirem by pocket
dosimeter,
which exceeded
his administrative
exposure limit of 2150 millirem
by 185 mi llirem.
The inspector
reviewed licensee
Health Physics
Procedure
HP-1, Radiation
Work Permits,
Revision
19,
February
7,
1984.
Paragraph
4. 18
of the procedure
stated:
"Under
no circumstances
shall
an individual exceed
his quarterly
exposure limit while working under
an
RWP."
.The inspector
determined
through discussions
with licensee
representatives
that the
worker's pocket dosimeter is normally not read until
he completes all of his
entries
and has exited the containment.
His pocket dosimeter
reading
was
recorded
on the
RWP timesheet
at the containment control point by a health
physics technician.
Licensee
representatives
stated that they rely on
tracking the workers'tay
time in the
steam generator with a
=top watch to
maintain exposures
less
than their administrative limits.
The inspector
noted that the "jump sheet" for the worker's
December
3,
1985 entry did
indicate that his total stay time in the
had
been the
maximum specified
on his "jump sheet,"
5 minutes
and
30 seconds.
The inspector discussed
with licensee
representatives
health physics
procedures
that
had
been applicable to the
work.
The only.
procedure that was identified by the licensee
was the
RWP procedure,
HP-l.
The inspector
was
shown
an internal
memorandum
dated April 4,
1984,
Monitoring Exposures
During Steam'Generator
Work, addressed
to all health
physics
personnel
from the Health Physics Operations
Supervisor which
specified dosimetry requirements
for partial
and full personnel
steam
generator entries.
A second internal
memorandum
(undated),
Coverage,
specified the health physics controls for steam generator
work
including dress
requirements,
dosimetry,
dosimetry issue
and dose recording,
health physics
coverage
and survey
and air sample
frequency.
This second
memorandum
was the only document identified by the licensee
which described
the
use of the
"jump sheets,".which
were the primary means
used
by the licensee
to control worker exposures
during this work.
The inspector also discussed
with licensee
representatives
the frequency of
their TLD readings
during the sludge lancing work.
The worker had
been
taken
up to and inadvertently past their administrative
exposure limit
entirely based
on pocket dosimeter
readings.
Although the worker's
TLD had
been
read at the
end of November
1985,
as part of the licensee's
normal
monthly TLD reading cycle, the worker's
November
1985,
pocket dosimeter
continued to be used for exposure
control purposes
for entries
on each of
the first three
days of December
1985.
Licensee representatives
stated that
some delay in receiving the monthly TLD read data is normal
since the
are processed
at the licensee'
corporate
headquarters
in Miami, Florida;
however,
more timely results
were possible -in special
situations.'he
inspector
reviewed the exposure
records for the other workers who had
participated
in the
sludge lancing.
None of the other
22 workers
had potential
exposures
in excess
of regulatory limits.
Jil
On January
30,
1986, the licensee
provided
a copy of the internal
investigation report to the Senior Resident
Inspector.
The report concluded
that the worker had not been
exposed
in excess
of the limits of
10 CFR 20. 101 and that his total exposure for the fourth calendar quarter of
1985
had been
2723 millirem. The report stated that the exposure
had been
obtained
by averaging
the values
on the two elements
of the
TLD worn by the
worker in December
1985,
and adding that to the whole body exposure
indicated
by his November
1985,
TLD reading.
The December
1985, value
represented
the appropriate
dose to the portion of the whole body that
had
been
exposed,
the bone marrow of the entire upper
arm.
The licensee's
report also stated that
an alternate
method of determining the individual's
whole body dose would be to calculate
the dose
received
by each
upper
arm
and assign that dose to the maximally exposed portion of the whole body.
Since only one whole body TLD had
been" worn and was relocated
to the arm
being placed in the
the licensee
determined
how long each
arm had
been
in the
and prorated the total dose indicated
on
the
TLD to each
arm.
The maximum whole body exposure
using this technique
was determined
to be 2545
mi llirem.
4.
Enforcement
Conference
An Enforcement
Conference
was held at the licensee'
Corporate
Headquarter
s
in Miami, Florida
on February
25,
1986, to discuss
the circumstances
of the
exposure
event
and the licensee's
evaluation of the worker's exposure.
The
following persons
were in attendance:
a.
Florida Power and Light Company
J.
W. Dickey, Vice President,
Nuclear Operations
K.
N. Harris, Vice President,
St.
Lucie
D. A. Sager,
Plant Manager,
St.
Lucie
J.
K. Hays, Director of Licensing
J.
L. Danek,
Corporate
Health Physicist
'.
C. Perle,
Senior Specialist
H.
F. Buchanan,
Health Physics Supervisor
R.
M. McCullers, Health Physics Operations
Supervisor
b.
Nuclear:Regulatory
Commission
0
J.
P. Stohr, Director, Division of Radiation Safety
and Safeguards
D.
M. Collins, Chief,
Emergency
Preparedness
and Radiological
Protection
Branch
C.
M. Hosey, Chief, Facilities Radiation Protection
Section
G.
R. Jenkins,
Director, Enforcement
and Investigations
Coordination Staff
S.
A. Elrod, Chief, Projects
Section
2C
R.
E. Weddington,
Radiation Specialist
R.
V. Crlenjak, Senior
Resident
Inspector,
St.
Lucie
During the meeting,
licensee
personnel
presented
discussions
of the
steam
generator
sludge lancing event.
The discussions
included their experiences
on this job during previous outages,
their investigation into the exposure
event, findings, conclusions
and corrective actions.
Licensee
representatives
stated that they believed that the root cause
of the event
was their finding that the direct reading dosimeters
underresponded
by 26-40
percent
when exposed
in the geometry worn by the
workers
(i.e., parallel to the arm and pointing toward the radiation source).
They
concluded that based
on
an evaluation of how long the worker had each
arm in
the
hand hole, the highest
exposed
upper
arm had received
2836 millirem and,that
would be assigned
as his quarterly whole body dose
~
NRC personnel
asked questions
relating to the licensee's
controls for the
sludge lancing work and their placement of dosimetry.
The licensee
was
requested
to provide Region II with *a copy of the internal report which
described
how the worker's dose
had been calculated.
Licensee
representatives
stated
a copy of the report would be sent to Region II.
Exposure
Evaluation
A copy of the licensee's
internal report of the worker's exposure
assessment
was received in Region II on February
26,
1986.
The report
described
four methods that
may be used to assess
the magnitude of the
worker's exposure.
All four -methods indicated that the worker's total
quarterly exposure
had
been
less that the
NRC limit of 3000 milli rem.
Of
the four methods,
the
one chosen
by the licensee that best
assessed
the
worker's exposure
was
a calculation of the dose received
by each of the
upper
arms
and assigning
the highest
upper
arm dose
as the whole body dose.
The inspector
used information that
had been
supplied
by the licensee
to
perform
a time and motion study to calculate
the highest
exposure that had
been received
by the lower portion of the worker's upper
arm just above the
elbow.
The calculation indicated that the lowest portion of the worker's
upper right arm had received
an exposure of approximately
4700
mi llirem and
the lower three
inches of the upper
arm had received
an exposure
in excess
of 3000 millirem.
The inspector also calculated that in order for the dose
measured
by the
TLD of 2667 millirem and the 4700
mi llirem calculated
dose
to be consistent,
the whole body TLD element in the badge
would have
had to
have
been approximately five inches
above the elbow.
The implied placement
of the
TLD was consistent with the statements
from the worker and the health
physics technician
covering the work in regard to the dosimetry placement.
During
a March 7,
1986 telephone
conversation
with the licensee's
Corporate
Health Physicist,
Region II personnel
explained the basis for their
conclusion that the worker had received
an exposure
to the lowest portion of
his upper right arm in excess
of regulatory limits.
Licensee
representatives
stated that the
TLD had been
placed
as low as possible
without hindering the free movement of the worker's
arm.
Region II
personnel
agreed that the TLD placement
had been
reasonable,
however the
licensee's
exposure
investigation
and assessment
had failed to adequately
take into account all relevant information,
such
as the
TLD placement
and
the dose rate gradient in the
handhole.
6.
Summary of Findings
Technician Specification
6. 11 required that procedures
for personnel
radiation protection shall
be prepared
consistent with the requirements
of
10 CFR 20 and shall
be approved,
maintained
and adhered
to for all
operations
involving personnel
radiation exposure.
10 CFR 20.201(b) required that each licensee
make or cause to be
made
such
surveys
as
may be necessary
for the licensee
to comply with the regulations
and are reasonable
under the circumstances
to evaluate
the extent of radiation
hazards that
may be present.
10 CFR 20.101(b) required
a licensee
to possess,
use,
and transfer its
licensed material
in a manner which precludes
whole body occupational
exposure
of any individual in a restricted
area to more than
3 rems to the
whole body in any period of one calendar quarter.
It was determined,
based
on the circumstances
surrounding the exposure
event, that the licensee's
radiological controls
and evaluations for the
sludge lancing work had not been
adequate.
This failure to
exercise
adequate
controls
had
a significant potential for causing worker
exposures
to exceed
NRC limits and
may have resulted in one worker receiving
a quarterly whole body dose to the lowest portion of his right upper
arm of
approximately
4700
mi llirem.
The licensee
used informal internal
memorandums
in lieu of approved
procedures
to specify the radiation protection controls for the
work.
Failure to establish
procedures
for personnel
radiation protection for the
work was identified as
an apparent violation of Technical Specification 6.11 (50-335/86-01-01).
The licensee
also failed to perform adequate
evaluations
of personnel
whole
body exposures
as were necessary
to ensure that exposures
were maintained
within the limits of 10 CFR 20.101(b)
as follows:
A worker's pocket dosimeter
was not routinely read until the worker
exited the containment.
Workers were permitted to make repeated
steam
generator
arm entries with time keeping
as the only exposure
control
measure.
This practice failed to consider the potential for changes
in
radiation levels
and the effect that would have
on the workers'tay
time.
Failure to evaluate
pocket dosimeter
readings prior to allowing
subsequent
arm entries
was identified as
an apparent
violation of 10 CFR 20.201(b)
(50-335/86-01-01).
b.
Workers were permitted to receive whole body exposure
up to the
licensee's
administrative limits based entirely on pocket dosimeter
data.
Event though the November
1985
TLD for a worker had been
read
on
November 30,
1985,
pocket dosimeter data continued to be used to
10
control his exposure
for each of the first three
days of December
1985.
When his December
1985
TLD was processed, it indicated that the
worker's cumulative exposure for the calendar quarter
was
3019
mi llirem.
Failure of the licensee
to evaluate
TLD'
at sufficient
frequency to assess
exposures
prior to exceeding
regulatory limits was
identified as
an apparent violation of 10 CFR 20.201(b)
(50-335/86-01-01).
The licensee
determined after the exposure
event that the direct
reading dosimeters
underresponded
26 to 40 percent
due to the geometry
in which they were exposed with the
end of the dosimeter
pointing into
the radiation field.
The effect of the underresponse
was that worker
exposures
were higher than they were thought to be since the licensee
was controlling exposures
to the pocket dosimeter total.
Failure of
the licensee
to adequately
evaluate their dosimetry devices
under the
conditions/geometry
that they would actually be used
was identified
as
an apparent violation of 10 CFR 20.201(b)
(50-335/86-01-01).
J
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