ML17304A589

Summary of 880914 Meeting W/Util in Region V Re Results of Util Reevaluation of 880522 Overexposure Discussed at 880817 Enforcement Conference.Supporting Info Encl

ML17304A589
Person / Time
Site:	Palo Verde
Issue date:	09/21/1988
From:	Yuhas G Office of Nuclear Reactor Regulation
To:	Office of Nuclear Reactor Regulation
References
EA-88-182, NUDOCS 8810030011
Download: ML17304A589 (94)

Text

Docket No. 50-529 EA 88-182 MEMORANDUM FOR FILE:

FROM:

SUBJECT:

Docket No. 50-529 Greg P. Yuhas, Chief Emergency Preparedness 5 Radiolcgical Protection Branch MEETING WITH REPRESENTATIVES OF PALO VERDE NUCLEAR POWER PROJECT (ANPP), TO DISCUSS THE RESULTS OF ANPP'S REEVALUATION OF THE MAY 22, 1988$

OVEREXPOSURE DISCUSSED AT ENFORCEMENT CONFERENCE OF AUGUST 17,1988 On Wednesday, September 14, 1988, members of the Region V Staff and ANPP met at 12:30 P.M. in the NRC Region V Conference Room to discuss the results of ANPP's reevaluation of the May 22, 1988 overexposure.

This meeting was requested by ANPP.

This matter had been previously discussed at an Enforcement Conference held at the Region V 'Office on August 17, 1988.

Attendees at the meeting included:

NRC Attendees:

Ross A. Scarano, Director Division of Radiation Safety 5 Safeguards (DRSS)

R. Pate, Chief, Reactor Safety Branch G. P. Yuhas, Chief, Emergency Preparedness 5

Radiological Protection Branch S. A. Richards, Chief, Engineer ing Section A. D. Johnson, Enforcement Officer H. S. North, Acting Chief Facilities Radiological Protection Section M. Cillis, Senior Radiation Specialist ANPP Attendees:

W. E. Ide, Plant Manager Unit 2 T. D. Schriver, Manager Compliance The agenda addressed at the meeting is included as Attachment 1.

Mr. Ide discussed the scope of the.licensee's initial:investigation performed after the overexposure event of May 22, 1988.

The information discussed by Unit 2 Plant Manager is contained in Enclosure (1).

Mr. Schriver addressed the licensee's findings resulting from a reevaluation that was conducted in response to NRC concerns expressed at the NRC/ANPP Enforcement Conference held in the Region V office on August 17, 1988.

The report documenting the reevaluation discussed by Mr. Schriver is contained'n Enclosure (2).

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Mr., Scarano stated his concern that the identified breakdown in the licensee's oversight groups was being presented

.as a radiation. protection problem and was not being given enough attention for their generic implication.

Mr.

Schriver assured that this was not the case.

He stated that, the issues identified as Items Y, YI and YIII in Section IX.of-Enclosure 2 were clearly generic in nature and are being treated as such by ANPP management.

Mr.

Schriver added that the recommended corrective actions identified as a result of the reevaluation were currently being reviewed by ANPP/APS management.

Greg P.

Yuhas, Chief Emergency Preparedness 5 Radiological Protection Branch Enclosures as stated cc w/enclosures:

J.

G. Haynes, ANPP W.,F. Quinn, ANPP R. Papworth, ANPP L. Souza, ANPP T.

D. Shriver, ANPP C.

N. Russo, ANPP U. Canady, ANPP L. Bernabei, GAP T. Hogan, ACC A. C. Gehr, Esq.,

Snell' Wilmer bcc w/enclosures:

T. Foley, NRR G.

Cook B. Faulkenberry J. Martin docket file Resident Inspector i'roject Inspector bcc w/o enclosures:

M. Smith; J.. Zoll.icoffer R QUEST C

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PY REQUEST C

PY REQUEST C

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ATTACHMENT 1.

MEETING WITH ANPP SEPTEMBER 14 1988 I.

Opening Remarks Purpose Scarano/Yuhas Discuss the results of the. addi'tional. review related to the

-May 22,.1988, overexposure event that ANPP/APS agreed to perform at the August 17, 1988, Enforcement Conference.

II.

Licensee Presentation.

III'. Closing Remarks Ide/Schriver ANPP/Scarano

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UNIT 2 OVEREXPOSURE I.

INVESTIGATION A.

MRITTEN STATEMENTS MERE TAKEN IMMEDIATELY AFTER THE EVENT..

B.

PLANT MANAGER'ONVENED A MEETING AT 7:00 AM ON MAY 23, 1988.

1.

REVIEMED EVENTS 2.

STA MAS ASSIGNED INVESTIGATION RESPONSIBILITY C.

AREA WAS SURVEYED 5/23/88.

D.

TLD TREE, MAS USED TO CONFIRM EXPOSURE SCENARIO ON 5/24/88 E.

SCE HEALTH PHYSICS ENGINEER AND ASSISTANT HEALTH PHYSICS MANAGER OVERVIEMED THE INVESTIGATION TO PROVIDE INPUT OF LESSONS LEARNED FROM THEIR OVEREXPOSURE. INCIDENT.

F.

RP STANDARDS SECTION CONDUCTED AN INDEPENDENT INVESTIGATION.

1.

~ OF DOSE ASSESSMENT 2.

OF ROOT CAUSE

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STA'S INTERVIEWED/DISCUSSED EVENT WITH 21 PEOPLE.

C H.

EXTENSIVE EVENT/INVESTIGATION REVIEW MEETINGS CONDUCTED BY PLANT MANAGER ON 5/25/88, 6/20/88, AID 6/21/88 I.

UNIT/EXECUTIVE MANAGEMENT MEETING CONDUCTED ON -6/27/88 J.

RP STOP WORK AUTHORITY QUESTIONNAIRE COMPLETED.IN UNIT 2 II.

ANPP EVALUATION A.

CAUSES 1.

ROOT CAUSE A.

INCOMPLETE DECONTAMINATION B.

INCOMPLETE SURVEY c.

INSUFFICIENT JOB PLANNING~

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-UNIT 2 OVEREXPOSURE (CONTINUED)

B.

INTERIM CORRECTIVE. ACTION 1.

ISSUED A MEMO TO UNIT 2 RP STAFF EMPHASIZING:

CAREFUL PRE:-JOB REVIEW OF SURVEY,

REP, DOSIMETRY AND SCOPE OF WORK.

'B.

VIGIL'ANT RP COVERA'GE.

c.

DOCUMENTATION AND RESOLUTION OF WORKER CONCERNS BEFORE START OF JOB.

2.

LETTER TO UNIT 2 RCA WORKERS TO INCREASE SENSITIVITY IN RADIATION PRACTICES..

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.UNIT 2 OVEREXPOSURE (CONTINUED)

C.

CORRECTIVE ACTION 1.

DECON A.

REVIEW METHOD OF ADDING WATER TO TRANSFER CANAL.

B.

REVIEW DESIGN OF PC/RD DRAIN PIPING.

c.

DEVELOP.PLAN FOR ADEQUATE DECON OF FUEL TRANSFER CANAL.

2.

SURVEYS a.

STRENGTHEN APPROPRIATE PROCEDURES

~ FOR SURVEYS.

B POLICY STATEMENT ISSUED TO RP MANAGERS DEFINING JOB COVERAGE SURVEY REQUIREMENTS.

c.

CONDUCT OVERVIEW REVIEW,OF SURVEYS.

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n. 'EVAL RELIABILITYAND ENSURE AVAILABILITY OF MONITORING EQUIPMENT (RO-7) 3.

JOB PLANNING A.

REP TO PROVIDE CAUTION ON BODY POSITION B.

RPM MANAGEMENT POLICY TO PROHIBIT RP, TECHNICIANS FROM ACTING SIMULTANEOUSLY AS JOB FOREMAN c.

EVALUATE NEED AND AVAILABXLITY OF TELEDOSXMETRY n.

EVALUATE UNIT 2 RP TECHNICIANS KNOWLEDGE OF STOP WORK AUTHORITY ISSUE LETTER FROM SITE RPM ON RP'S AUTHORITY AND RESPONSIBILITY TO STOP WORK 4

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UNIT 2 RP MANAGER HAS BEEN DIRECTED.

'TO RESOLVE WORKERS CONCERNS AND IMPROVE COMMUNICATIONS e.

MEMO STRESSING COMMUNICATIONS TO LINE ORGANIZATION. PERSONNEL D.

ADDITIONAL CORRECTIVE. ACTIONS 1.

INDIVIDUALNOTIFIED OF DOSE IN, WRITING JUNE 27, 1988 2.

PROCEDURE 75AC-9ZZ01 REVISED TO'EQUIRE WRITTEN NOTIFICATION OF OVEREXPOSURE 3..

EVALUATE, AND ENHANCE HOT PARTICLE PROGRAM.

4.

EVALUATE AND CLARIFY RESPONSIBILITY OF RP AND ALARA.

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UNIT 2 OVEREXPOSURE (CONTINUED)

III. ANPP EVALUATION OF INSPECTION REPORT A.

ANPP HAS REVIEMED THE SUBJECT INSPECTION REPORT AND HAS RESOLVED THE MINOR COMMENTS WITH MR. H. CILLIS

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'rizona Nuclear Power Project COMPANY CORRESPONDENCE'ATE:

TO:

Sta; I Ext:I fgOM:

St+ N ExLI September 13, 1988 Distribution As Indicated Below T. D. Sht iver /

'6148 2521 8UBJEGT: Vnft 2. Overexposur e Attached fs the final report addressing the evaluation conducted into the Unit 2 Overexposure Event.

The report incorporates the resolution to coaatents provided. by you.

Based upon the results of the evaluation, I have proposed correctfve 'actfons which are discussed in Section IX. It fs requested that you review the information provided in the report and the recomended'orrective actions to determine if these actions will be effective in resolving the concerns.

If you have any questions regarding the information provided fn the report or the recommended corrective actions, please contact me..

TDS/kj Attachment.

Dfstributfon:

J.

G. Haynes R. M. Butler Q. F. quinn L. G. Papworth M.,E. Ide J.

D. Driscoll J. E. Kirby ccrc D. N. Stover L. B., Spfers J. M.'flls

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TABLE'F"CONTENTS

'I PAGE

NUMBER, Preface........,...

Section I Management Involvement Section II Potential Precursors

~ 1b 7'ection III Personnel

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Section IV Problem Identification and Resolution Section V

CommunicationsSection VI Investigation TechniquesSection VII Program Adequacy Section VIII Conclusion

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10 20 23 25 28 Section IX Recommended Corrective Actions 31

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PREFACE In response to NRC concerns expressed at the ANPP/NRC Enforcement Conference held in Malnut Creek, California on August 17.,

1988',

a re-evaluation of the Unit 2 Overexposure Event was conducted.

The intent of the evaluation was to provide management a broader perspective concerning the overexposure event.

The specific scope of.the. evaluation is contained, in Attachment 1 of this report. It was not the intent of this evaluation to: categorize or consolidate deficiencies previously identified in gA Audits, gA investigations, SPEER's and other evaluations that have been conducted.

Because of the nature of this evaluation the overall conclusions address management..systems vice event specific issues.

Therefore, the recommended corrective, actions are intentionally.board. scoped designed to provide in-depth program evaluations which will in turn lead to overall program, enhancements.

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SECTION I MANAGEMENT INVOLVEMENT SCOPE:

To evaluate: the adequacy of management involvement in the RP area and to assess the. impact of recent loss of RP management personnel.

EVALUATION:

In the overall assessment of,'management involvement several concerns were identified'elating: specifically to the event

and to the. more generic, problems currently being identified.

in the RP area..

The individual'ssues are addressed in.the following concerns.

CONCERN I:

Although the Refueling/Containment L'ead RP technician expressed: concerns about the painting of the cavity.

The individual did. not directly supervise or,monitor the work.

A review of the RRAC Transaction Log for the. month of Hay, 1988', indicated that the lead entered the,RCA only fourteen (14) times during the month of which only four (4) were containment entries.

No entries were logged on the day of the event with the last recorded containment.en'try being on Hay 19,

1988, two (2) days prior to the event.

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CONCERN.2'-

Although the Unit 2 RP'anager was aware of concerns expressed, about the planned evolution there. is'.no documented

.evidence that the i~dividual toured 'the general area to

assess, the actual working conditions.

A review of the RRAC Transaction L'og for the"month of'Hay, 1988, indicates only one (1) containment entry which was made after the event occurred.

CONCERN 3:

Although concerns were identified by both the ALARA Supervisor and the acting Site RPM, as discussed in reference (2),.neither. individual toured the general area. to assess the actual wor king conditions.

A.review: of RRAC Transaction Log for the month of May; 1988', indicated, no containment entries for the. ALARA Supervisor and only.one (1) entry for the acting Station RPM after the event occurred.

NOTE:

CAS/SAS transaction log indicates one (1) containment entry for the ALARA Supervisor on May 3, 1988.

CONCERN 4.

On March 29, 1988 an ARC technician exceeded his PVNGS Administrative Dose Limit while performing the washdown/pumpdown

.of the il side Steam Generator bowls.

At the.time the individual received the dose which caused him to exceed the administrative limits he was being monitored by an ARC RP technician (reference Radiological Controls Problem

,Report'2-&8-024)..

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CONCERN 4:

'(CONTINUED)

A subsequent-reply, to the problem report from the ARC Site Manager on April, 7, 1988, provided specific corrective 0

actions that were not effectively implemented.

CONCERN 5:

'esponsible.

RP management-did, not initiate corrective action within the time frame requested by guality Audits when it was identified that the ALARA Committee was not performing its intended function. (reference equality Assurance Audit Report number 88-008 and Corrective Action,Report CA88-0036)

CONCERN: 6 The position of.Station RPM has not been;permanently.filled since the position was: vacated.

SUMMARY

Based:upon the identified concerns insufficient management involvement in the work activity on May,22, 1988; is considered to be a contributing factor to the overexposure event.

Although concerns were expressed by the-lead technician and the responsible RP Manager neither individual:

monitored the activity while in progress-Insufficient first line supervision involvement in the activity was,compounded by. the Site RPM and the ALARA group not being totally effective in responding to identified concerns.

Although concerns were.identified.by both the

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SUMMARY

(CONTINUED)

ALARA Supervisor and the acting Station RPM neither individual personally evaluated the actual working conditions.

It is considered a positive aspect that the Unit 2 Plant Manager met with the ALARA Supervisor, acting Station RPM, Unit 2 'RP Manager and the Unit 2 Mork Control Manager to, discuss and: resolve the identified concerns prior to making the. final decision to paint the area.

However, without having first hand knowledge of the working conditions present in the canal area by the responsible RP management personnel it is believed 'that a sound. decision could not have been made.

From a more generic perspective, responsible RP management personnel;not'roperly evaluating identified deficiencies and

.implementing timely corrective actions resulted in missed opportunities to potentially avoid events such as the overexposure.

Specifically, the event. which occurred on March 29,.1988,,could be viewed as an opportunity to implement corrective actions which may have eliminated several of the contributory causes of the overexposure that occurred on May 22, 1988. If the corrective actions recommended by. the contracting organization had been effectively implemented, certain aspects of the overexposure event such as inadequate pre-job planning, use of proper dosimetry, failure to stop-work and the improper use of a radiological survey could potentially have been eliminated prior to the, event.

Another example of a management system not being properly implemented by the responsible 0

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(CONTINUED) organization is the ineffectiveness of the. ALARA Committee.

Although it is not apparent that an ALARA Comnittee review would have altered or prohibited the planned work activity, the failure to complete the required review of the proposed work activity represents a missed opportunity to avoid the event.

The absence of the ALARA Committee involvement and the identification of procedural noncompliances as discussed in other sections of this report indicate of a lack of sufficient RP management attention in the RP area.

An overview of the specific concerns identified in this area and.of the overall conclusions that were subsequently made identifies specific instances where individuals did not fulfillall their responsibilities which potentially contributed to the overexposure event.

During the course of the evaluation a lack of strong centralized RP management control both prior to and after the reorganization which was implemented on November 'I, 1988 was identified.

This is illustrated by the Station RPM not ensuring effective implementation of corrective actions to address the ALARA Committee deficiencies and the procedural adherence problems identified by the guality Assurance Organization (reference gA Audit Report Number 87-017,88-008 and Corrective Action Report CA88-0036).

Another indicator of this lack of centralized RP management control is in the divergence noted in the implementation of the RP program requirements in the

'ndividual units.. Although the dissimilarities such's the 0

SUMMARY

.(CONTINUED)'ethod'sed to access the RCA and processing of problem reports are procedurally permitted or not addressed in a prescriptive manner, they do, indicate a lack of central'ized control.

The weakness in the. RP management control was further compounded'y the resignation of the Central RP Manager and the Radiation Protection/Chemistry Manager.

The departure of these key individuals aggravated the management control situation.

The position of'entral RP Manager has been filled, however, the position of the Radiation Protection. and Chemistry Manager which was, vacated on Apri.l 29,,1988. remains vacant.

As a result, one offer was extended on June 24, 1988, 'however, it was subsequently refused on July 6, 1988.

Additional candidates have been interviewed'however, the position is still vacant.

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SECTION II PRECURSORS SCOPE:

To evaluate potential precursors and determine.the adequac

,of corrective actions taken.

EVALUATION:

This assessment included review of NRC inspection reports and ANPP responses from July 1987 to July 1988.

CONCERN 1:

The NRC has expressed concern regarding ANPP personnel knowledge levels in the area of radiation protection in at least six inspection reports over the past year.

In July, 1987 an inspector questioned the-number and significance of.-

problems and" contamination events in Units 1 and 2.

Since that time and prior to the overexposure event, three separate inspection reports enumerated examples of l'ack, of knowledge of (or adherence to) the action levels for,radiological

posting, REP requirements, and. personnel. monitoring reauirements.

These criticisms were directed primarily at

.hot particle control and detection and control'f high radiation areas.

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CONCERN 2:

Deficiencies 'in surveying and personnel.monitoring have been identified in,numerous NRC inspection reports since July, 1987.

There were several'eported incidents of surveys not being performed (one level IV violation) or being incompl'ete and at least one incident involving a survey error discovered during NRC investigation of an apparent, posting violation.

Particular concern has been expressed over hot particle detection methods and the monitoring instrumentation in use.

CONCERN 3:

In October,,

1987 an NRC inspector identified numerous practices inconsistent with the requirements of 75RP-OZZOl, Radiological. Posting.

During a follow-up inspection in

November, 1987 two radiation. area posting violations (one level IV;. one level V) were cited.

The November inspection

,report characterized ANPP procedures and technician training as inadequate,to assure,,prompt corrective action when unexpectedly high radiation is encountered during surveys.

At present another potential radiation area control violation is pending..

CONCERN 4:

On at least three. occasions NRC inspectors raised the question of ANPP personnel's adherence to RP requirements.

These same inspection reports also noted a few instances of apparent miscommunication and/or disagreement which came to the inspectors'ttention during the course 'of their inspection activities.

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These concerns reveal that ANPP did have indications of

NRC-perceived deficiencies in several areas that are directly related to'roblems that are now being identified.

Extensive corrective actions, particularly in response to the November, 1987 inspection report were implemented.

The corrective

'actions. were primarily.directed at increasing each employee's awareness of radiological concerns.

As a result, improvements were made in the RP area particularly with respect to hot: particle-control.

The corrective actions taken in response to the specific concerns appear. to have been adequate,

however, as part of'hose corrective actions, ANPP relied upon establishment of the new organization.

and; its expected increased management involvement and accountability to resolve escalating NRC concerns in other areas.

As discussed in the overall 'RP area other. sections of this report, the reorganized structure has not provided the direct RP management involvement that was expected. due to management vacancies in the organization..

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SECTION III PERSONNEL SCOPE:

To evaluate the training 'and qualifications of RP personnel.

EVALUATION:

An evaluation was performed to assess the qualification and training of RP personnel.

In particular, those individuals involved in the Unit 2 overexposure event which occurred on Hay 22, 1988 were evaluated.

During this assessment, several issues were identified and are addressed in the following concerns.

CONCERN I:

The Refueling/Containment Lead RP Technician responsible for providing direction to both Junior and Senior Radiation Protection Technicians has not received any formal supervisory training.

'CONCERN 2:

Outage Contract Radiation Protection Technicians are not.

required to attend formal task oriented classroom training on PVNGS site specific requirements.

CONCERN 3:

The "Contractor Outage RP Technician On-The-Job Training gualification Card" currently being utilired is not contained in the current revision of Department Instruction RP-021, "Radiation Protection Technician gualification Guide".

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CONCERN 4:

Department Instruction RP-021, Rev.

6 requires the Radiation Protection and Chemistry Manager to approve individual qualifications.

However, only the Unit 2 RP Manager approved the qualification card for both the direct and contract personnel involved in the overexposure event.

CONCERN 5:

The RP contractor responsible for monitoring the work which resulted in the overexposure event had no previous commercial nuclear power experience.

SNMARY:

A review of the concerns noted two (2) specific issues that, although not directly contributing to the event, may have been factors that could have altered the circumstances which led to the overexposure.

The contractor RP technician who was supervising the work that. led to the overexposure had previous experience in supervising lab technicians and had approximately eleven (11) months field experience in supervising RP related field. activities; however.,

he had no previous commercial nuclear power experience.

Through previous work experience the individual was qualified to AAS 3.1 1978 requirements, however, the complexity and scope of work required during a refueling outage would appear to require more practical field experience than the individual 0

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(CONTINUED) had acquired.

Although this is a subjective opinion, the individuals.actions both prior to and after the event tend to substantiate the conclusion.

Another aspect is the training of the ANPP lead RP technician.

As in the case with the contractor involved in the event, the ANPP lead was qualified in accordance with ANS 3.1-1978 requirements.

Additionally the lead had previous experience in supervising field activi'ties.

However, the.individual has received no formal ANPP classroom training on developing supervisory skills.

The ability to effectively communicate concerns and obtain resolution is an important attribute that personnel performing in a. supervisory capacity must possess.

In the case of the overexposure the. lead'echnician had concerns about the planned'ork;

however, the individual was.

unsuccessful in effectively communicating those concerns to the appropriate levels of management for resolution.

In evaluating the training/qualification area from a more generic perspective several issues were identified that related directly to the training of both ANPP and contractor RP technicians.

Prior to the overexposure event the Radiation Protection Standards Supervisor expressed concerns about the training provided to contract RP technicians employed For outage support to the Training Manager.

The current practice requires the contract individual to attend a standard "Radiation Morker" course designed for general employees.

This generalized training is supplemented in the specific 0

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(C0NTINUEO) units by completing required reading lists and demonstrating practical knowledge which is recorded in the individual's "On-The-Job Training gualification Card".

The Unit 2 RP-Manager and the Radiation Protection Standards Supervisor have stated that this practice is insufficient in training contract personnel in the PVNGS site specific requirements.

As a result, the Radiation Protection Standards Supervisor requested that specific training programs be developed as a

cooperative effort between the RP Standards Group and the Training Department for contractor RP technicians in a memo to the Training Hanager dated February 10, 1988.

The request included the development of an.interim program and the establishment of a permanent program.

The permanent program is currently under development, however no specific responsibilities were assigned and no followup on the request was done by either the RP Standards Group or the Training Department and therefore the interim program was never initiated. It is not believed that this issue directly impacted the overexposure

events, however as previously discussed, the lack of training specifically for the RP technician and generically for the general employee has resulted in other errors which have been identified in the RP

area, such as failures to properly frisk, properly "dress out" and adhere to radiological postings. '

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SUMMARY

(CONTINUED),

As part of,this portion of the evaluation, the contract. under which ARC was performing work.was reviewed.

The initial concern deal.ing with verification of the contractor's program for qualifications, which prompted the review of the contract, is currently being addressed in the response to Corrective Action Report (CAR) number CA88-0059.

During the review of the contract, it was noted that the work to be performed was to be under the direction of ANPP..

The specific contractural requirement states "All decontamination services are to be performed under the direction of the APS Radiation Protection Supervision".

'The wording of the contract permits contract individuals to perform tasks under the supervision of their own employees.

As noted in section I. of this report, the lack of ANPP management involvement is considered to be, a contributing factor in the overexposure event.

Therefore, the practice of permitting contract employees to.perform work without ANPP supervision is also considered a contributory cause.

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SECTION'Y PROBLEM IDENTIFICATION AND RESOLUTION

.SCOPE:

To assess the effectiveness of the current problem reporting mechanisms and'esolution processes.

EVALUATION:

In assessing the effectiveness of,probl'em identification and resolution several concerns were identified which related:

directly to-,the overexposure event and provided indications of more generic concerns.

CONCERN 1:

The Quality, Assurance Organization and the RP Standards-Group identified concerns germane to the.overexposure event however they were not totally effective 'in obtaining the necessary corrective actions.

CONCERN 2:

The Radiation Protection and Chemistry manager did not implement e'ffective corrective action, to address, concerns identified by the oversight groups.

The failure of the ALARA committee to discharge their responsibilities. beginning in

March, 1987 was not identified by the QA Organization until April, 1988 and the RP 'Standards Group until March, 1988 although.this was prior to the. overexposure.

event it was.not

.acted on appropriately,'y the RP and Chemistry Manager.-

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CONCERN 3:

The methodology utilized by the oversight groups to elevate identified concerns to the proper level of management has not always resulted in timely and.effective corrective action.

SUMNRY:

The concern relating specifically to the event was inappropriate actions on the part of RP management to implement timely and effective corrective action when it was identified that the ALARA Committee was not functioning.

As discussed in Section I of this report, the failure of the ALARA Committee to evaluate the proposed painting of the refueling cavity represented a missed opportunity to avoid the event.

The breakdown of this management system represents another missed opportunity to eliminate a

potential contributory causes of the overexposure.

The individual concerns identified in this section indicate multiple problems within the management system designed to identify. problems and to obtain the necessary resolutions.

Through a review of gA Audit reports, gA Hot Line Investigations and the RP Standards Evaluation, it appears that the system was effective in identifying existing deficiencies and potential precursors.

However, the efforts to raise these concerns to the appropriate level of management to initiate the required corrective actions were not tota11y effective.

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SUMHARY:

(CONTINUED)

In the case of the RP Standards evaluation, the failure of the AL'ARA Committee to perform its required function was identified in March, 1988.

However, the conclusion of the.

evaluation stated that the RP program was being properly implemented in all respects.

The responsible manager was made aware of the deficiency, but took no positive action to correct it.

Based upon the conclusion, which is customarily used to assess the results of the evaluations, senior level management had no reason to initiate follow-up action to ensure problems were corrected.

The failure of the responsible manager to resolve the deficiency and the failure of the evaluation system to provide follow-up action resulted in an identified deficiency remaining uncorrected.

The guality Assurance involvement in the RP area. has been

.extensive as indicated by Audit Numbers87-017 and 88-008, Hot line allegation investigation numbers88-033 and 88-034, the Semi-Annual Trend Report dated April 22, 1988 and numerous monitoring reports.

These documents if evaluated from an overall perspective would have indicated a generic problem in both the ALARA and RP areas.

Specifically to the event, as discussed in Section I of this report, the failure of the ALARA Committee to meet was identified through guality Assurance Audit Number 88-008 and documented on Corrective Action Report (CAR) CA8&-0036 which was prepared on April 4, 1988.

On May 20, 1988, the date the e

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SUMMARY

(CONTINUED)

CAR response was due, the responsible RP management requested an extension to the due date for responding to the CAR thereby permitting a contributory cause of the overexposure event to remain uncorrected.

Although individual indicators were identified by the guality Organization which would have, if evaluated. from a broader perspective, indicated a

potentially generic problem in the RP area particularly with procedural adherence.

A review of the corrective actions taken to address the individual identified deficiencies indicates that the actions were effective but no overall assessment was done which may have resulted in actions to prevent this overexposure.

This is best illustrated when comparing the results documented in the Semi-Annual Trend Report which evaluated the deficiencies identified during the period of July 1, 1987 to December 31, 1987 with the results of the Semi'-Annual gA Repot't which evaluated the deficiencies identified durihg the period of January 1, 1988, through June 30, 1988.

The comparison shows a continued procedural adherence deficiency in the RP area and substantiates the indication that the corrective actions taken in response to identified deficiencies were narrow in scope and failed to both identify the root cause and to initiate appropriate corrective actions.

Additional generic concerns in the RP area were addressed in the investigations conducted as a result of two (2) Hot Line Allegations (reference Hot Line 88-33 and 88-34).

Numerous concerns were. identified and are currently being evaluated to

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SUMMARY

(CONTINUED) identify the necessary corrective. actions.

The evaluation of these investigations concluded that.the they were adequate in scope and depth.

However, the necessary actions.have not been effected in a timely manner, nor was the lack of timely action raised above the level of RP management.

As illustrated by the examples discussed, the ineffectiveness of the corrective action system is apparent in the RP area.

Specifically, the failure of the responsible RP management personnel to implement timely and effective corrective action coupled with the failure of the oversight groups to ensure the necessary actions were taken or elevated to the appropriate levels of management, potentially contributed to the overexposure and the continuing problems being identified in the RP area.

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SECTION V COWUNICATIONS PURPOSE:

To assess the formal and informal. lines of communications utilized in the Radiation Protection Program at Palo Verde and identify potential weaknesses.

EVALUATION:

An evalua'tion of communications was conducted ys it pertains to the overexposure event of May 22, 1988 and to the Radiation Protection Program overall.

This review identified several issues as discussed in the following concerns:

CONCERN I:

The interface between the Unit Radiation Protection Managers.

and the Site RPM is not clearly defined.

CONCERN 2:

The resignation of key management personnel in the RP area disrupted the establ'ished: lines of communication.

CONCERN 3:

The Unit RP personnel did not utilize all avenues of communications to express their concerns.

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CONCERN':

The stop work notification process is not formally addressed.

CONCERN 5:

The,authority of.

RP. management personnel (i.e, Site RPH and the Radiation Protection/Chemistry Manager) is not clearly understood by the RP managers or the RP technicians.

SUMMARY

Inadequate communications were identified as a contributory factor in the SPEER which investigated the overexposure event.

Tbe concerns identified in, this evaluation are considered.'to expand the contributory causes addressed in the SPEER.

The responsible RP lead and contract technician voiced concerns to the Unit 2 RP Manager about the proposal to,paint the refueling cavity.

According to the individuals'tatements provided after the event, their concerns were not resolved.

However, neither individual ut'ilized the established communication tools available for the resolution of these types of concerns nor did they elevate their concerns beyond 'their immediate supervision.

No documentation, could be. found that woul'd indicate the identification of their concerns on ALARA Problem Reports or Radiological Control Reports.

The use of these types of documents, may have avoided the confusi'on discussed in the SPEER.

SUHHARY:

(CONTINVED)

Another tool not utilized by the lead or responsible technician was the issuance, of a Stop Mork.

Confusion exists concerning the reasons why the work was not.stopped.

However, a review of the, procedural controls governing the Stop'Mork Authority indicates that the process is, not clearly defined.

Although the authority is defined, the conditions warranting, the issuance of a Stop Mork are generic, in nature resting in part on the opinion of the technician in. charge.

This may require the technician to make judgement calls with no specific, procedural guidance.

This may inhibit the issuance of the orders.

The lack of established

.lines of coseunications and authority are considered to be a contributory cause to the overexposure event.

Additionally, as discussed in Section I of this.

evaluation, the resignation of key management individuals adversely impacted the managerial, stability in the RP area.

This management turnover, also impacted the established communication channels.

The breakdown in communications between the var.ious RP Organizations is considered.

a contributory cause to the repetitive deficiencies currently being identified.

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.SECTION VI INVESTIGATION TECHNI(UES SCOPE:

'Evaluate the. adequacy of the SPEER with regards to the overexposure event.

EVALUATION:

In evaluating the adequacy of the investigation conducted into the overexposure event several issues were identified as discussed in the following concerns:

CONCERN I:

The SPEER did not identify the failure of.the ALARA Committee to evaluate the, proposed painting of the refueling cavity prior to the commencement of work.

CONCERN 2:

The report did not address the weaknesses of applicable

.management systems such:as direct management involvement or the effectiveness of the oversight committees as addressed in this evaluation which were subsequently determined to be contributory 'causes of, the overexposure event.

'CONCERN 3:

The report did not identify procedural inadequacies and violations in the 'ALARA area.

SUMNRY:

Based upon the results of the evaluation, it has been determined that the SPEER was scoped such that the results 0

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SUMMARY

(CONTINUED),

did not identify all the potential contributory causes.

A review conducted of the SPEER and other recently conducted SPEER's indicates that the investigations were. directed primar.ily at human factor performance and equipment response.

However, the investigations did not evaluate the effectiveness of- "management systems" such as direct management involvement or the adequacy of'he duties performed. by the oversight committees.

Although the adequacy of,the.investigation conducted, into the events obviously has no impact on the event itself the results are relied upon to ensure that sufficient corrective action is taken to prevent recurrence.

Although the implementation of the corrective actions recommended in the SPEER would be effective in preventing occurrences similar to the specific event, the generic weaknesses in the RP program itsel'f would not have been corrected as a result of the SPEER. '

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To determine.if existing programmatic controls were properly implemented.

EVALUATION:

A.review of the current Administrative Controls and implementing. procedures was conducted to assess the adequacy of. procedural'mplementation.

As a result of this evaluation, the following concerns were identified.

CONCERN I:

Violations of Radiation Protection administrative and implementing procedural controls were identified as discussed in a memo issued 'by the Acting Radiation Protection/Chemistry Hanager.

CONCERN 2:

ALARA procedures lack sufficient direction to ensure compliance.

SUHMARY:

The procedural controls in the RP area were not changed in any substantial manner following the reorganization.

Prior to the reorganization, the activities of the RP technicians were controlled by specific individual'anagement personnel and did not rely on perscriptive procedural controls.

The latitude inherent in the.procedures was established to permit II li "1

SUMMARY

(CaNlrNUEO) management flexibilityin the implementation of the program.

However, after the reorganziation which redistributed the responsibility and accountability for the implementation of.

the 'program and the resignation of two (2) key individuals the need for more, perscriptive procedural guidance began to be recognized.

As.a result, the units began instituting individual policies.to. specify the spec'ific controls which were 'not provided:. in the existing procedures.

This has resulted in two areas of weakness:

1)

The day-to-day operation of the unit Radiation Protection Oepartments have become more individualized.and 2)

The violations o'f.procedural controls identified during this review can.be directly,attributed to insufficient direction being provided.

Thus, major improvements in the Radiation Protection area and the role of the Site Radiation Protection Manager will not. be totally effective until the procedures provide more perspective guidance. '

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SUMMARY

(CONTINUED)

Although the procedural deficiencies addressed are not considered to have directly impacted the overexposure event they are considered a contributory cause to the event and to the generic deficiencies currently being identified in the RP area.

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SECTION VIII'ONCLUSION As discussed in the preface of this document the intent of the evaluation was not to categorize or consolidate deficiencies previously identified in other documents addressing the RP area.

Based upon this approach, the issues identified and the resultant recommended corrective actions are-programmatic in nature.

The overall conclusion drawn from this evaluation is that the decision made to paint the refueling cavity was correct based upon the information available to management at the time the decision was made, that the subsequent investigation conducted into the overexposure event was properly conducted within the procedural guidelines currently in place and that the corrective actions recommended as a result of the investigation were appropriate.

However, this evaluation identified broader concerns relating to the overexposure event and other RP deficiencies currently being identified.

As discussed in Section VI, the current investigative techniques utilized at PVNGS are oriented towards personnel, performance directly relating to the event and equipment deficiencies.

The SPEER program was not developed to evaluate or address broad programmatic issues such as those identified in this evaluation.. It was recognized, however, that an evaluation of the effectiveness of the management systems associated with an event is necessary in the overall investigation and subsequent determination of the "root cause.

As a result, an eva1uation of the effectiveness of the investigation process was initiated.

An effort independent of this event was initiated by Site Management to develop a comprehensive investigation program. '

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.SECTION VIII CONCLUSION (CONTINUEO)

In.particular., the revised program recognizes that the depth and scope of investigations are dependent upon the circumstances surrounding the event.

Therefore,, events have been categorized by type 'with each category requiring the impl'ementation of specific.'investigative techniques.

Additionally, the new investigation program defines the methodology utilized. to document identified, deficiencies and obtain the necessary corrective actions.

As discussed. in Section IV, the methods to effectively inform management of existing deficiencies, to properly identify the necessary:,corrective

actions, and to ensure implementation of those actions. have not been consistent in obtaining positive results.

Currently, there are numerous problem identification programs in use at PVNGS.

There is no consistency in either the reporting mechanisms used to inform.:management or the methods used to ensur e and verify implementation of corrective actions.

The results of this evaluation confirm the need to reassess the effectiveness of the existing problem.identification programs in establ,ishing priorities for responses to the, various. identifying organizations and with particular emphasis placed'n the methodology employed.by ove'rsight organizations, to ensure the proper level of management is promptly and accurately informed when timely corrective action is not taken. '

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Prior to commencing the work which led to the overexposure the appropriate levels of management evaluated the necessity of doing the work and weighed the potential exposures against the benefits of proceeding.

Based upon the information available and the assumption that the work would be performed under controlled conditions, the decision that was made is considered appropriate.

However, the evaluation identified various concerns relating to this area that although not directly related to the overexposure

event, have and are contributing to the continuing problems being identified in the RP area.

The most significant of these issues are the need for stronger centralized leadership due to a vacancy in the RP and Chemistry Nanager's position and the lack of formally established lines of authority and communications between the various RP groups.

Associated with the need for stronger centralized leadership is the need for more perspective procedural

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controls which implement the RP program.

The evaluation identified various procedures that, although they correctly address current commitments, were vague in nature which could lead to divergence in their implementation

and, potentially, to procedural noncompliance.

Based upon the results of the evaluation, specific corrective actions designed to address each identified concern are considered inappropriate.

The concerns are indicators of more generic issues that are pr ogrammatically based.

Therefore, the recommended corrective actions discussed in Section IX of this report are designed to provide a broad scoped evaluation of each generic area of concern and to develop a comprehensive corrective action plan.

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SECTION IX RECOMMENDED CORRECTIVE ACTIONS I. Fill the, vacant Radiation Protection/Chemistry Manager's position a.-

Action:

R. 'M. Butler II.

Clearly define the authority of the Radiation Protection/Chemistry Manager and procedural.ly establish formal lines of communications a.

.Action:

J.

M. Sills III. Clearly define the rylationship between the Unit RP Managers, Central RP Manager and Unit Chemistry Managers a.

Action:

Radiation Protection/Chemistry, Manager.

IV.

Conduct a detailed'valuation of performance in the RP area including associated areas such as the ALARA.program to determine the adequacy of training, staffin'g, procedural controls, organization, etc.

a.

Action:

J.

M'. Sills Conduct an evaluation of the existing problem identifications and resolution processes to determine their effectiveness a.

'Action:

M. F. guinn

'VI.

Obtain approval and implement the PVNGS Incident Investigation Program a.

Action:

R. J'. Adney i~

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SECTION IX RECONHENDED CORRECTIVE ACTIONS (CONTINUED)

VII.

Continue. development and implementati'on of the contractor training program in the RP area a.

Action:

M. F. Fernow

,.'III. Evaluate the need for performance based supervisory skills training for recently promoted supervisor personnel a.

Action:

M. F. Fernow II O.

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ENCLOSURE 3 PROBLEMS HAVING GENERIC IMPLICATIONS 1.

The licensee's. investigation process for problem identification was determined to.be ineffective with respect to the identification of broad issues with management system and generic implications.

The investigative process was scoped to address specific personnel/system problems.

2.

The mechanisms for maintaining management awareness of corrective actions and the status of deficient conditions was determined to be ineffective.

3.

The lack of continuing formal training programs for developing supervisory/

managerial skills.

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