ML17291B113
| ML17291B113 | |
| Person / Time | |
|---|---|
| Site: | Columbia  |
| Issue date: | 11/14/1995 |
| From: | Murray B NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| Shared Package | |
| ML17291B111 | List: |
| References | |
| 50-397-95-30, NUDOCS 9511210026 | |
| Download: ML17291B113 (24) | |
See also: IR 05000397/1995030
Text
ENCLOSURE 2
U.S.
NUCLEAR REGULATORY COMMISSION
REGION
'
V
Inspection Report:
50-397/95-30
License:
Licensee:
Washington Publ'ic Power Supply System
3000 George Washington
Way
P.O.
Box 968.
MD 1023
Richland,
Facility Name:
Nuclear
Project-2
Inspection At:
Richland,
Inspection
Conducted:
September
25-28 '995
Inspectors:
L. T. Ricketson,
P.E..
Senior
Radiation Specialist
Plant Support Branch
M.
P.
Shannon,
Radiation Specialist.
Plant Support Branch
Approved:
urray,
>e
,
ant
upper
rane
//-/4r f5
a e
Ins ection
Summar
AAI
A t d.'
ti
.
d i
p ti
f th
di ti
p t ti
program's
response
to events related to high high (greater
than
1000 mrem/hr)
and very high (greater
than 500 Rads/hr) radiation area doors,
including:
initial determination of event significance,
event investigation,
root cause
analysis,
resolution of problem evaluation
requests
(PER),
comprehensiveness
of corrective actions.
communications,
verification, procedural
adequacy,
and
potential for significant exposure.
Results:
Plant
Su
orb
~
The dispositioning
manager for PER 295-0492
was not sensitive to the
significance of the event.
This affected the comprehensiveness
and the
timeliness of the implementation of corrective actions.
Improvements in
the
PER process
have
been
made since the occurrence of the events
(Section 2.1).
95ii2i002h 951.ii4
ADOCK 05000397
8
-2-
~
The licensee's
investigation of events
described in PER 295-0492
and
PER 295-0955 were not thorough.
The events
were not viewed as
significant; therefore,
less eff'ort was devoted to determining the
causes.
Had more detailed investigations
been performed,
an adverse
trend involving personnel
performance
and
a poor verification program
may have been identified.
The investigation of PER 295-0927
was more
thorough.
However, the investigation determined only what happened
during the event.
not what caused
the event (Section 2.2).
~
The radiation protection manager did not follow the guidance in
Procedure
PPH 1.3. 12A, Revision 2, concerning the root-cause
analysis
and, therefore,
did not meet
management
expectations.
The licensee
missed
an opportunity to identify an adverse
trend and
a problem with
the verification program (Section 2.3).
Radiation protection personnel
did not meet management
expectations
for
resolving problem evaluation
requests
in a timely manner
(Section 2.4).
A violation of Technical Specification
6. 12.2 was identified involving
=
the failure to lock
a door controlling access
to an area with radiation
levels greater
than
1000 mRem/hr (Section 2.5).
Communication of information regarding the first event
was poor and
may
have contributed to the second
event (Section 2.6).
~
A Non-Cited Violation was identified involving the failure to follow a
procedure.
Radiation protection personnel
missed
two earlier
opportunities to identify the procedural
violation.
The oversight
program for high high and very high radiation areas
continued to be
weak, in part because,
management's
expectations
with regard to high
high and very high radiation area surveillances
did not include the
rigorous
and consistent
use of the guidance provided to ensure that
technical specification requi rements
were met (Section 2.7).
~
The procedure for the control of access
to high high and very high
radiation areas
did not address all regulatory requi rements
(Section 2.8).
~
The potential for personnel
radiation
exposure in excess of regulatory
limits occur ring as
a result of the events
was low (Section 2.9).
Summar
of Ins ection Findin s:
Violation 397/9530-01
was opened
(Section 2.5).
A Non-Cited Violation was identified (Section 2.7).
-3-
Attachments:
~
Attachment
1
- Persons
Contacted
and Exit Meeting
~
Attachment
2 - Chronology of Events
1
BACKGROUND
-4
DETAILS
From May 7 to August 17,
1995, three potential violations occurred involving
doors to areas controlled in accordance
to Technical Specification 6. 12.2.
A
special
NRC inspection
was performed to evaluate the potential for unplanned
personnel
radiation exposure
associated
with each event
and to review the
corrective actions taken by the licensee for each of the following three
events.
1.1
Event
1
On May 7,
1995,
a door (C-115) to a high high radiation area
on the 437-foot
elevation of the radwaste building was discovered
by licensee
personnel
to be
. unlocked.
Radiation 'levels within the area
were greater than
1000 milli rems
per hour.
Technical Specification
6. 12.2 requires
such areas to be locked to
control inadvertent
personnel
entry.
A planned entry into the area
was
conducted
ear lier in the day by a mechanical
maintenance
worker under the
observation of a radiation protection technician.
The door was normally
controlled by a padlock
and
a chain.
The chain was usually passed
through the
hand wheel in a manner that prevented
the wheel
from being turned, thus,
locking the door.
On this day, the padlock
was locked;
however,
the chain
was
not routed
so that it restricted the movement of the wheel,
and the door could
have
been
opened.
A radiation protection supervisor
discovered
the unlocked
door and licensee
personnel
initiated
PER 95-0492 to document the problem and
track corrective actions.
1.2
Event 2
On August 9
~
1995.
licensee
personnel
discovered
the
same door (C115)
on the
437-foot elevation of the radwaste building was not locked.
This time the
chain
and the lock were on the floor nearby.
An entry into the
room was
completed the previous afternoon
by an equipment operator
under the
observation of a radiation protection technician.
The licensee initiated
PER 295-0927 to document the event.
1.3
Event
3
On August 16.
1995, the licensee identif'ied that the door to the traversing
incore probe
room,
an area that was posted
and controlled as
a very high
radiation area.
had only one lock i nstead of the two locks required
by
Procedure
PPM 11.2.7.3.
PER 295-0955
was initiated to document the event.
2
NRC REVIEW
The
NRC inspectors
reviewed the problem evaluation
requests
associated
with
the events.
investigation reports,
proposed corrective actions,
correspondence
by the quality assurance
organization related to the corrective actions,
applicable
implementing procedures,
radiation protection log book entries,
key
-5-
control log entries,
survey information, training materials,
and applicable
night orders
from radiation protection
management.
In addition to per forming
document reviews, the inspectors
conducted interviews and performed
independent
radiation surveys.
2. 1
Initial Determination of Event Si nificance
When the events occurred,
the licensee's
corrective action program was
implemented using the following procedures:
~
PPM 1.3. 12.
"Problem Evaluation Request
(PER)," Revision
20
~
PPM 1.3. 12A, "Processing
Problem Evaluation Requests,"
Revision
2
Both procedures
were revised again
on September
18,
1995 'fter the events
occurred.
.At the time of the events. it was the dispositioning manager's
(in this case
the radiation protection manager'). responsibility to determine the
significance of. the events.
Section 6.3 of Procedure
PPM 1.3. 12A stated that
the dispositioning
manager
is to "Review the
PER to verify whether or not a
Root Cause Analysis is required.
Attachment 8.8 should
be used for guidance."
Attachment 8.8
~
"Root Cause Analysis Screening
Guide," included guidance in
the areas of reactor operations
(Section
1. 1). health physics
(Section 1.2).
radwaste transportation
(Section 1.3),
and miscellaneous
matters
(Section 1.4).
Event
1
Even though the event described
in PER 295-0492
was identified as being
contrary to the requirements
of Technical Specification
6. 12.2 and might have
presented
the potential for significant personnel
radiation exposure, it was
not determined
by the licensee to war rant
a root-cause
anal'ysis.
Because it
was not considered significant, the search for all possible
causes
was not
rigorous
and the timely implementation of corrective actions
was not
emphasized.
See Section 2.5 for
a discussion of the corrective actions.
Event
2
PER 295-0927
was considered significant because
the event represented
a
significant adverse
trend or failure affecting
a quality program or plant
safety,
according to the note in Block 19 of the problem evaluation request
form.
Event 3
PER 295-0955
was not considered
by the licensee to be significant.
The event
was seen merely
as
a procedural violation.
A root-cause
analysis
was not
determined to be necessary.
No adverse
trend in the verification program.
as
discussed
in Section 2.7
~ was identified.
-6-
Event
3
PER 295-0955
was not considered
by the licensee to be significant.
The event
was seen merely as
a procedural violation.
A root-cause
analysis
was not
determined to be necessary.
No adverse trend in the verification program,
as
discussed
in Section 2.7,
was identified.
The inspectors
noted that major changes
were made in the way problem
evaluation
requests
were dispositioned with the issuance of Revision
3 of
Procedure
PPM 1.3. 12A on September
18.
1995.
Some of the changes
included:
The introduction of the concept of a "Significant PER," [Section 4. 19j; the
determination of the significance of problem evaluation
requests
during
morning meetings of site management
[Section 6.2j; and the requirement that
all significant problem evaluation
requests
have
a formal root-cause
analysis
performed [Section 6.4.6j.
An attachment entitled, "Significant PER Screening
Guide." replaced the "Root Cause Analysis Screening
Guide."
The new screening
guide in'eluded
as significant
"Any operation or condition prohibited by the
plant's Technical Specifications."
Such guidance, if followed, would have
served to raise the level of attention received
by PER 295-0492;
however, the
events'hich
are the subject of this inspection,
occurred before the
implementation of Revision
3 of the Procedure
PPM 1.3. 12A.
Conclusion
The
PER dispositioning
manager
was not sensitive to the significance of the
first event.
This affected the comprehensiveness
and the timeliness of'he
implementation of corrective actions.
Improvements in the
PER process
have
been
made since the occurrence of the events.
2.2
Event Investi ation
The inspectors
interviewed licensee
personnel
and performed record reviews
and
determined the following concerning the licensee's
investigation process:
Event
1
According to the mechanical
maintenance
worker involved in the event described
in PER 295-0492.
licensee
representatives
never interviewed him regarding
details of the event.
The radiation protection supervisor
who validated
PER 295-0492 confi rmed this.
The radiation protection technician involved in
the event stated that
he was interviewed
a few days after the event.
Event
2
The event described
in PER 295-0927
was recognized
by the licensee
as being
significant and
an incident review board was established
on August
9
~ 1995, to
review the ci rcumstances
surrounding the event.
The incident review board
interviewed the individuals involved and reviewed records related to the
event.
According to the incident review board report dated August 16,
1995.
the incident review board concluded that the root cause of the incident was
,Ql
-7-
unknown.
Also according to the report.
".
.
. it was decided to deviate
from
the normal
IRB process
and,
instead,
have
an independent
investigator
investigate the incident in hopes of resolving what occurred."
The
independent
investigator interviewed personnel
with known or potential
knowledge of the event
and concluded that the individuals involved "failed to
lock the door."
Event
3
Although it was identified on August 17,
1995, that the traversing incore
probe
room door did not have two locks. the licensee did not determine. until
prompted
by the inspectors,
that. the second
lock was
removed
from the door on
-August 1,
1995.
Records
were available to confirm that one lock was re-cored
on that date
and the other lock removed;
h'owever,
the licensee
had not taken
action to determine the length of time the violation existed.
The
investigation also did not identify that radiation protection personnel
performing weekly verifications of high high radiation area
and very high
radiation area controls
(as discussed
in Section 2.7) failed to identify the
violation on August
7 and
14 '995.
Conclusion
The licensee's
investigation of events
described
in PER 295-0492
and
PER 295-
0955 were not thorough.
The events
were not viewed's significant; therefore,
less effort was devoted to determining the causes.
Had more detailed
investigations
been performed,
an adverse trend involving personnel
performance
and
a poor verification program
may have
been identified.
The
investigation of PER 295-0927
was more thorough.
However, the investigation
determined only what happened
during the event.
not what caused
the event.
2.3
Root-Cause
Anal sis
Procedure
PPM 1.3.48,
"Root Cause
Analysis'
" Revision 5, Section 1.0 states,
"Root cause analysis is required
when there is
a 'Significant Condition
Adverse To'uality.'s described
in 10 CFR 50, Appendix B, Criterion XVI."
Procedure
PPM 1.3. 12A, Section 6.3,
requi res the dispositioning
manager
to
"Review the
PER to verify whether
or not
a Root Cause Analysis is required.
Attachment 8.8 should
be used for guidance."
Attachment 8.8, Section 1.2
includes guidance that
a root cause analysis is to be performed
when
a
breakdown in the radiation safety program involving a number of violations
that are related (or if isolated, that are recurring) that collectively
represent
a potentially significant lack of attention
or carelessness
toward
licensed responsibilities.
Procedure
PPM 1.3. 12A. Section 6.3, also states,
"PPM 1.3.48 should
be used in
the preparation of a root cause analysis determination
and documented
in a
Root Cause Analysis report."
Procedure
PPM 1.3.48 included discussions
on
root-cause
analysis
techniques
such as:
change analysis,
barrier analysis,
event
and causal
factor charting, fault-tree analysis,
human performance
evaluation
system,
and management
oversight
and risk-tree ana'lysis.
A
root-cause
analysis report format was provided with instruction to attach the
reports to the associated
problem evaluation request.
Event
1
Since the event was not recognized
as significant,
no formal root cause
analysis
was performed.
The cause of the event described
in PER 295-0492
was
determined
by the radiation protection organization to be failure to
self-check
(Root-Cause
Code PE0205).
Event
2
According to the note in Block 19 of the problem evaluation
request
form, the
event described
in PER 295-0927
represented
a significant adverse trend or
failure affecting
a quality program or plant safety.
The licensee
recognized
that the event
was significant and planned to perform
a formal root-cause
analysis.
However, it was decided that the independent
investigation would
suffice for the root cause analysis
because,
"nothing further can be. gained or
investigated."
The guidance of Procedures
PPM 1.3. 12A and
PPM 1.3.48
was not
followed.
None of the root-cause
analysis
techniques
described in Procedure
PPM 1.3.48 were used.
Had licensee
personnel
performed barrier analysis
as
part of a root-cause
analysis,
they would have identified that one of the
barriers,
which did not work was the verification program.
The verification
program is discussed
in Section 2.7.
The inspectors
reviewed the results of the independent
investigation
and noted
that the independent
investigator.
from the licensee's
Nuclear
Safety
Issues
Program.
concluded that the individuals "failed to lock the door."
The
investigator
made
no conclusion concerning the cause of the event.
The
inspectors
interviewed the investigator
and determined that he was not aware
that the investigation
was substituted for a formal root cause analysis,
and
he stated that he had not conducted the investigation
as
he would a root cause
analysis.
The cause of the event was listed on the problem evaluation request
resolution form as less than adequate
human performance.
Specifically,
root-cause
codes
were listed as,
"system alignment. tagout, restoration
not
verified" (PE0201),
and
"Oocuments not followed correctly" (PE0209).
Event 3
No formal root cause analysis
was performed after the third event.
The cause
of the event described in PER 295-0955
was determined
by the radiation
protection organization to be. procedural
noncompliance
(Root-Cause
Code PE0209).
Even though this event shared
one of the
same root-cause
codes
as the previous event. it was not seen
as part of an adverse trend.
Licensee
personnel
did not identify a problem with the verification program,
as
discussed
in Section 2.7
~
and the event
was seen
as
an isolated
example.
-9-
'onclusion
The radiation protection manager did not follow procedural
guidance outlined
in the root-cause
analysis
implementing procedure
and. therefore,
did not meet
management
expectations.
The licensee
missed
an opportunity to identify an
adverse trend
and
a problem with the verification program.
2.4
Resolution of Problem Evaluation
Re uests
Procedure
PPH 1.3. 12A, "Processing
Problem Evaluation Requests,"
Revision 2.
Section 5.3, stated that the dispositioning manager
"should disposition
PERs
within 30 days after initiation of the PER."
The inspectors
constructed
the time lines in Attachment
2 from document
reviews
and personnel
interviews.
This information demonstrates
that
a significant amount of time was expended
before the
PERs were dispositioned
through the submission of appropriate
and comprehensive
corrective actions.
Conclusion
Radiation protection personnel
did not meet management
expectations
of
resolving the
PERs in a timely manner.
2.5
Corrective Actions
The inspectors
interviewed licensee
personnel
and performed record reviews in
order to evaluation the licensee's
corrective actions related to the three
events.
Procedure
PPH 1.3. 12A. "Processing
Problem Evaluation Requests,"
Revision 2,
Section 6.4.4 states.
"The corrective action should
be completed within 60
days of PER disposition.
Event
1
The cause of the event described
in PER 295-0492
was determined
by the
radiation protection organization to be failure to self check.
The proposed
corrective action was to replace the chains
used to secure
high high radiation
area doorswith padeyes
(hasps).
The corrective action,
although appropriate
for the specific problem, did not directly address
the identified cause.
This
was first identified in a memorandum
dated July 26,
1995,
by quality assurance
personnel
reviewing the initial. proposed corrective actions.
The insoectors
agreed with this conclusion
and noted that the padeyes
were not instaljed
unti 1 September
14,
1995. too late to prevent the second event.
The licensee
missed
an opportunity to identify and correct problems
caused
by workers
who
did not understand
management.'s
expectations
related to the verification
process,
as discussed
in Section 2.7.
The response
from radiation protection
personnel
to the July 26 memorandum,
on August 15,
1995,
was,
"The corrective
-10-
action for failure to self-check is addressed
by
PER 295-0201 that is
addressing
Human Performance
Issue for WNP-2 plant wide basis."
The August
15
response
also stated
PER 295-0927 would thoroughly address
corrective actions
related to the self-checking issue.
Event 2
The cause of the event described
in PER 295-0927
was listed on the problem
evaluation request
resolution
form as less than adequate
human performance.
Six corrective actions
were originally proposed.
In a memorandum
dated
September
18,
1995, the radiation protection manager
was informed that the
disposition of PER 295-0927
was incomplete.
The memorandum stated,
"Although
the corrective actions that are already proposed
may add improvement to the
current Health Physics
program,
they do not identify a method by which future
personnel
errors of the same type can be minimized.
The
CAP [corrective
action plan] ¹6, which is to 'Evaluate the need for improved training for
personnel
.
.
. .'oes
not adequately
implement such
La] process
at this
time."
The reviewers stated further. that an evaluation is
a precursor .to
determining effective corrective action
and does not ensure training will be
performed.-
The inspectors
agreed with the assessment~.
Also, the inspectors
determined
through interviews that there
was
no attempt
made to notify the
general
working population of such problems in a timely manner,
such
as
through safety meetings or site newsletters.
Event
3
The cause of the event described
in PER 295-0955
was determined
by the
radiation protection organization to be procedural
noncompliance.
In a
memorandum
dated
September
15,
1995, the radiation protection
manager
was
notified of the return of PER 295-0955
because it did not contain cor rectiv'e
action.
Radiation protection personnel
indicated that appropriate corrective
action would be addressed
by
PER 295-0927,
CAP ¹6.
As stated
above,
PER 295-0927.
CAP ¹6 was found to be unacceptable.
For each of the
PERs
~ the initial corrective actions
were found to be
unacceptable,
when reviewed
by quality assur ance personnel,
or nonexistent.
The causes
for all events
were determined to fall under the general
heading of
"work practices,"
according to Procedure
PPH 1.3.48,
Attachment 8.6,
indicating an adverse trend.
Technical Specification
6. 12.2 requi res, in part, that in addition to the
requirements
of Technical Specification
6. 12. 1, areas
accessible
to personnel
with radiation levels
such that
a major portion of the body could receive in
1
hour
a dose greater
than
1000 mrems shall
be provided with locked doors to
prevent unauthorized entry.
The inspectors
determined that Events
1 and
2
were
a violation of Technical Specification 6. 12.2.
Further.
because
the
second
example of this violation could have reasonably
been expected to have
been prevented
by corrective actions for the first example
had they been
implemented in a timely manner.
the inspectors
determined this licensee-
identified violation did not meet criteria for exercise of discretion,
as
outlined in Section VII of the
NRC Enforcement Policy (397/9530-01).
Conclusion
A violation of Technical Specification
6. 12.2 was identified involving the
fai lure to maintain
a lock door for an area in which the radiation levels
exceeded
1000 mrems/hr.
2.6
Communications
Based
on information gathered
through personnel
interviews
and records
reviews, the inspectors
evaluated
the quality of the licensee's
communications
regarding these
events.
- Event
1
According to a statement
to the inspectors
made by the mechanical
maintenance
worker involved in the event described
in PER 295-0492 'he mechanical
maintenance
worker was not aware that he was involved with a high high
radiation area control issue until informed by the inspectors
on September
26,
1995.
The incident evidently had not been discussed
at safety meetings
held
within the maintenance
department.
During another
interview with NRC
inspectors,
the radiation protection technician involved in the event stated
that he was not aware that
a problem evaluation request
was written and was
not aware of corrective actions that were taken to prevent recurrence.
The
licensee
could produce
no record of discussions,
safety meetings,
or general
communications
in which the plant workers were made aware of'
Technical
Specification violation and of corrective actions taken to prevent its
recurrence.
Event
2
According to a statement
made to inspectors
by the radiation protection
technician involved in the event described
in PER 295-0927,
he was not aware
of the previous event (described in PER 295-0492).
The inspector determined
that verification.
as it relates to high high radiation area
and very high
radiation area
locks was not addressed
in the licensee's
general
employee or
radiation worker training.
Conclusion
Communication of information regarding the first event
was poor
and
may have
contributed to the second
event.
-12-
2.7
Verification Pro
ram
The licensee relied on two forms of verification to ensure that Technical
Specification required locks were in place.
The first was the independent
verification by a second
person that doors to high high radiation areas
and
very high radiation areas
were locked after entries to the areas
were
completed.
The independent verifier did not have to be
a radiation protection
technician.
Any worker could perform the verification.
The second
form of
verification was performed
by radiation protection technicians
during weekly
routine assignments.
Radiation protection technicians
were required to verify
that high high radiation
areas
and very high radiation areas
were properly
locked.
The licensee
experienced
problems with both forms of verifications.
In the events, described
in PER 295-0492
and
PER 295-0927 'orkers
signed the
key log book verifying that the door (C115) to the high high radiation area
was properly locked.
In the first event.
the individuals did not physically
test the lock and chain to verify that the particular configuration kept the
door from being opened.
In the second
event, the workers obviously did not
communicate well and
no observations
or physical
checks
were performed.
The
inspectors identified no evidence of willful wrongdoing by the individuals
responsible f'r locking the doors
and performing the verification.
There was
no logical reason for the individuals to subject themselves
to possible
disciplinary action.
However, the inspectors
noted that there were variations
in the worker's understanding
of what was meant
by the requirement to verify
that the areas
were properly locked.
To some workers. verification meant
physically checking the locks and chains: to others it was simply an
observation or perhaps
a verbal confi rmation.
As discussed
in Section 2.6,
management's
expectations
for the verification program
as it relates to high
high and very radiation area
door locks were not included in the licensee's
general
employee or radiation worker training.
The radiation protection technicians
that performed weekly verification checks
on August
7 and 14.
1995, did not identify that there
was only one lock on the
door of the traversing incore probe
room,
an area controlled as
a very high
radiation area.
This condition existed
from August
1 until it was identified
by licensee
personnel
on August
17 '995.
Event 3 was
a violation of
Procedure
PPM 11.2.7.3 which stated,
"Accessible very high radiation areas
shall
be maintained double-locked."
The procedural
requirements
exceeded
the
requirements
of Technical Specification 6. 12.2 and
10 CFR 20. 1602.
The
inspectors
determined that this failure constitutes
a violation of minor
significance
and is being treated
as
a Non-Cited Violation, consistent with
Section
IV of the
Also. the weekly verifications did not identify unti 1 the week of the
inspection
(on September
27.
1995) that the lock at the wet well had not been
re-cored at the
same tike as the other high high radiation area
locks.
Cores
were changed in the other
locks
on approximately August 1.
1995.
Re-cored
-13-
high high radiation area
padlocks were wrapped with a bright green
band to
distinguish them from other
locks and were highly visible.
The inspectors
were informed at the start of the inspection that all high high radiation area
locks had been re-cored.
In NRC Inspection
Report 50-397/95-21.
the inspectors
concluded that the
oversight program for high radiation areas
was weak.
This was based
on
finding that radiation protection technicians
were not aware of the number of
areas,
which were requi red to be verified.
A checklist including each
door to
be verified as locked was not used for guidance.
The licensee's
record of
weekly verification included
a single verification signature
and only stated
that high high radiation areas
and very high radiation areas
were checked.
The licensee
took action to address this concern
and during the current
inspection,
the inspectors
were shown
a checklist with 16 high high and/or
very high radiation areas.
Licensee representatives
stated that the checklist
was used for guidance but was not expected
by management
to be taken into the
field or kept as
an official record.
Conclusion
A Non-Cited Violation was identified involving the failure to follow a
procedure.
Radiation protection personnel
missed
two earlier opportunities to
identify the procedural violation.
The oversight program for high high and
very high radiation areas
continued to be weak, in part because,
management's
expectations
with regard to high high and very high radiation area
survei llances did not include the rigorous
and consistent
use of the guidance
provided to ensure that technical specification
requirements
were met.
2.8
Procedures
Procedure
PPN 1.2.2,
"Plant Procedure
Preparation,"
Revision 20,
Attachment 20. defines the following terms:
Shall
- Used to denote regulatory requirements,
external
commitments
and
selective specific management
direction.
Should
- Used to denote
recommendations
but not enforceable
regulatory
requirements
and management
expectations.
(Hanagement
expects
each
employee using plant expectations
to carry out "should" statements
unless
circumstances
prevent or necessitate
deviation.
Departures
from
recommendations
should be done after supervisory concurrence.)
The inspectors
reviewed Procedure
PPH 11.2.7.3,
"High and Very High Radiation
Area Controls," Revision
10, to determine if the procedure
conformed to the
above guidance
and noted,
as
an example,
that Section 5.2.6.e stated,
"When
exiting
a high high radiation area.
health physics
personnel
should lock the
door.
-14-
This was inconsistent with Section 5.2.2,
which stated,
"Accessible high high
radiation areas
shall
be maintained
locked whenever
reasonably possible."
Not only was Section 5.2.6.e inconsistent with Section 5.2.2,
but it was
inconsistent with the regulatory requirement of Technical Specification
6. 12.2
which states,
in part. "In addition to the requi rements of Specification
6. 12. 1, areas
accessible
to personnel
with radiation levels such that
a major
portion of the body could receive in
1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br />
a dose greater than
1000 mrems
shall
be provided with locked doors to prevent unauthorized entry
.
.
. Doors
shall
remain locked except during periods of access
.
Radiation protection personnel
responded to inspectors'omments
by initiating
a procedure
change
form which changed
the "should" in this section to the word
"shall."
The inspectors
noted other examples of instructions that did not convey that
regulatory requirements
were the basis for the particular procedural
step.
Procedure
PPH 11.2.7.3,
Section 4.3, stated,
"Provisions should be made for
timely surveys to identify and post with precautionary notices.
the areas
and
systems that
may become high or very high radiation areas."
Contrast this to
which states.
that each licensee
shall
make or cause to be
made,
surveys that
may be necessary
for the licensee to comply with the
regulations in this part and are reasonable
under the circumstances
to
evaluate the potential radiological
hazards that could be present,
and
10 CFR 20. 1902, which states,
that each licensee
shall post each high and very
Procedure
PPM 1.2.2 did not define the terms "will" and "must."
However,
Procedure
PPH 11.2.7.3,
Section 5. 1.8, stated.
"Personnel will receive,
at
a
minimum,
a briefing of the radiological conditions in the area prior to
entry."
The regulatory requi rement.
10 CFR 19. 12. states,
that all
individuals working in or frequenting
any portion of a restricted
area shall
be kept informed of radiation in such portions of the restricted
area
and in
precautions to minimize exposure.
Procedure
PPH 11.2.7.3,
Section 5.2.4 states,
"Entry into high high radiation
areas
greater
than or equal to 1000 mrem/hr will be controlled by the issuance
of an approved
.
.
. ."
Technical Specification
6. 12. 1 requi res,
in part,
that entrance into high radi ation areas
be controlled by requi ring issuance of
a radiation work permit.
Procedure
PPH 11.2.7.3,
Section 3.2, states.
"Personnel
must have received the
required radiological training before being allowed to high or very high
radiation areas."
Technical Specification 6. 12. 1 requi res,
in part, that
entry into such areas
.
.
.
may be made after the dose rate levels in the area
have
been established
and personnel
have
been
made knowledgeable of them.
Licensee representatives
stated that
~ even though the terms "will" and "must"
were not currently defined by procedures
they were interpreted
as meaning
"shall."
Licensee
representatives
indicated that they would be considering
ways to address
the presence of such terms in their procedures.
-15-
The inspectors
acknowledged that the licensee
could implement
management
expectations
with statements
containing the word "should," and that the
licensee
could allow flexibility with respect to management
expectations.
However, the examples listed wer e instructions that were necessary
to
implement regulatory requirements.
Therefore,
using the licensee's
definitions from Procedure
PPN 1.2.2, "shall" was the proper term to ensure
that licensee
personnel
understood
the regulatory significance.
In order to
evaluate the action to be taken by the licensee with respect to undefined
terms,
such
as will and.must.
and to evaluate
more fully whether the wording
contained in other radiation protection procedures
correctly implements
regulatory requirements,
the inspectors identified an inspection followup item
(397/9530-02).
Conclusion
The procedure for the control of access
to high and very high radiation areas
did not appropriately
convey all regulatory requirements.
2.9
Potential
For Si nificant Ex osure
In order to determine whether there existed
a substantial
potential
for
personnel
exposure to radiation in excess of regulatory limits, the inspectors
toured the 437-foot elevation of the radioactive waste building,
and on
September
27.
1995,
one of the inspectors.
accompanied
by a radiation
protection technician,
performed
independent
radiation measurements.
The radiation measurements
made
by the inspector
were in good agreement with
the licensee's
measurements.
General
area radiation levels were approximately
1.6 rems per hour.
The inspector identified one area that measured
approximately
15 rems per hour at 30 centimeter s and 500
per
hour
on
contact.
The inspector determined that it would be difficult to place
a major
portion of the whole body within 30 centimeters of this area
and that it would
be unlikely that personnel
would be in such
a position long enough to receive
a radiation exposure in excess of regulatory limits.
Should
an individual be
in the area
long enough to receive
an overexposure, it would be likely that
the alarming dosimeter.
requi red for entry into the radiological controlled
area,
would alert the individual before the exposure
could occur.
During
NRC Inspection 50-397/95-16,
the inspectors
noted that there
had been
14 examples of individuals entering the radiological controlled area without
alarming dosimeters.
During this inspection,
the inspectors
found that the
licensee
had identified one additional
example since the end of the refueling
outage.
The inspectors
determined that the rate of personnel
entry into the
radiological controlled area without an alarming dosimeter
was low. and the
rate was decreasing
as workers
became
more familiar with the use of the
dosimeters.
-16-
The inspectors
also noted that Door C115 was massive
and opening the door was
a laborious task,
requiring that the hand wheel
be turned
many times.
Thus
the likelihood of an inadvertent entry to the .high high radiation area
was
low.
Had there
been
an inadvertent
entry, it was unlikely that an individual
would have received exposure in excess of regulatory limits.
Event
3 was unlikely to result in personnel
radiation exposure
because
personnel
entry was controlled by
a second lock.
Conclusion
The potential for personnel
radiation exposure in excess of regulatory limits
occurring as
a result of the events
was low.
0
1
PERSONS
CONTACTED
1. 1
Licensee
Personnel
ATTACHMENT 1
- P. Bemis, Director Regulatory
and Industrial Affairs
- V. Parrish,
Vice President
Nuclear Operations
T. Alton'echnical Specialist
D. Dinger. Health Physics Operations
Supervisor
- C. Foley, Licensing Engineer
J.- Hunter, Health Physics Craft Supervisor
C.
Leon, Technical Specialist
~J.
Muth, Manager Quality Support
- W. Rigby, Health Physics
Supervisor
V. Shockley, Assistant to the Radiation Protection
Manager
~J.
Swai les,
Plant General
Manager
- D. Swank,
Manager Licensing
J. Tate,
Equipment Operator
- J. Wiles. Qual.ity Assurance
Engineer
1.2
NRC Personnel
.
- R. Barr, Senior Resident
Inspector
- Denotes personnel
that attended
the exit meeting.
In addition to the
personnel
listed, the inspector contacted
other personnel
during this
inspection period.
2
EXIT MEETING
An exit meeting
was conducted
on September
28,
1995.
Ouring this meeting.
the
inspector
reviewed the scope
and findings of the report.
The licensee
expressed
the position that the wording used in its procedures,
as discussed
in Section 2.8
~ did not result in non-compliance with regulatory requi rements.
The licensee did not identify as proprietary,
any information provided to, or
reviewed
by the inspector.
0
-2-
ATTACHMENT 2
CHRONOLOGY OF EVENTS
Event
1
May 7,
1995
June
6
(30 Days)
June
8
(32 Days)
July 14
(68 Days)
July 26
(80 Days)
August
15
(100 Days)
September
27
(143 Days)
Door C115 was discovered
unlocked.
PER 295-0492
was
initiated.
Proposed corrective actions were due in 30 days.
A request
was
made by radiation protecti,on personnel
to
extend the deadline to June 30.
1995
A work order to install hasps
on all high high radiation
area
doors
was initiated.
The radiation protection organization submitted
a proposed
corrective action that required the replacement of chains
with padeyes, or hasps.
In a memorandum to the radiation protection manager
from
the'egulatory
support
manager,
the proposed corrective actions
were returned
and deficiencies in the actions
were
identified.
The radiation protection organization
was asked
to respond
on or before August 12.
1995.
The radiation protection organization
responded
and stated
that
PER 295-0201
and
PER 295-0927 would thoroughly address
corrective actions related to the self-checking issue.
PER 295-0492
was
reopened to include additional corrective
actions.
'
-3-
Event
2
August
8
August 9
(1 Day)
August 11
(3 Days)
August
16
(8 Days)
August 21
(13 Days)
September
18
(41 Days)
September
25
(48 Days)
Planned entry into a high high. radiation through Door C115.
Door C115 was discovered
unlocked.
PER 295-0927
was
initiated.
A nuclear safety issues
program lead investigator
was asked
to independently investigate the incident.
Memorandum containing the results of the independent
investigation
was sent
fr'om the incident review board
chairman to the plant manager.
Radiation protection manager
approves
proposed corrective
action.
In a memorandum to the radiation protection manager
from the
regulatory support manager,
the proposed corrective actions
were returned
and deficiencies in the actions were
identified.
The radiation protection organization
was asked
to respond
on or before October 8,
1995.
The radiation protection organization submitted additional
corrective actions.
Event 3
August
17
September
5
(19 Days)
September
15
(29 Days)
The door to the traversing incore probe
room was identified
as not having two locks are required
by procedure.
PER 295-
0955 was initiated.
The radiation protection organization
responded with
proposed corrective action.
In a memorandum to the radiation protection
manager
from the
regulatory support manager,
the proposed corrective actions
were returned
and deficiencies in the actions were
identified.
The radiation protection organization
was asked
to respond
on or before October 5,
1995.
P