ML18065B124
| ML18065B124 | |
| Person / Time | |
|---|---|
| Site: | Palisades  |
| Issue date: | 12/13/1997 |
| From: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML18065B122 | List: |
| References | |
| 50-255-97-15, NUDOCS 9712230386 | |
| Download: ML18065B124 (15) | |
See also: IR 05000255/1997015
Text
U.S. NUCLEAR REGULA TORY COMMISSION
Docket No:
License No:
Report No:
Licensee:
Facility:
Location:
Dates:
Inspectors:
Approved by:
9712230386 971213
ADOCK 05000255
G
REGION Ill
50-255
50-255/97015(DRS)
Consumers Power Company
Palisades Nuclear Generating Plant
27780 Blue Star Memorial Highway
Covert, MI 49043-9530
November 5-7, 1997
R. Glinski, Radiation Specialist
S. Orth, Senior Radiation Specialist
Gary L. Shear, Chief, Plant Support Branch 2
'
.
Division of Reactor Safety
...
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EXECUTIVE SUMMARY
Palisades Nuclear Generating Plant
NRC l'nspection Report 50-255/97015
This inspection was conducted to review a high radiation area posting incident and the
associated radiological surveys which were conducted for clean waste filter transfer work. The
inspection also included a review of various aspects of radiation protection training, the
corrective action program, and the communication of radiation protection expectations to the
Chemical and Radiological Services (C&RS) staff. The following conclusions were reached:
Overall, postings in the plantwere consistent with the radiological conditions documented
on the radiological area status sheets. However, one violation for the failure to post a
high radiation area was identified. Other postings that were inconsistent or lacked the
proper material to mainta.in the postings in place were also identified. The current
contaminated area posting practice appeared to cause confusion for plant personnel and
may have contributed to instances where rope barricades were found down at
contamination areas throughout the plant (Section R1 .1 ).
Routine radiological surveys were generally done in accordance with station procedures,
and the surveys were adequate to inform workers of radiological conditions. However,
three examples of a violation of Technical Specifications were identified as C&RS staff
did not perform surveys to verify a high radiation area boundary or the extent and
magnitude of contamination in the clean waste filter transfer room and failed to forward
survey data to the duty health physicist for review and signature (Section R1 .2).
One violation for the failure of a health physics technician to be aware of dose rate levels
or have a radiation dose rate meter prior to entry into a high radiation area was identified.
The lack of a questioning attitude by experienced C&RS staff regarding the downed high
radiation area posting, the failure to utilize available information to determine whether the
downed high radiation area posting was correct, and the lack of a clear communication of
management expectations were identified as weaknesses (Section R4.1 ).
Radiation protection training for plant personnel adequately addressed radiological and
radiation protection issues. Several minor inconsistencies between training materials and
plant procedures regarding contamination areas and radiological surveys were identified
(Section R5.1 ).
The corrective action program was effectively implemented in accordance with station
procedure. The root cause evaluation conducted in response to the high radiation area
posting incident identified two violations and other significant problems. The
recommended corrective actions appeared appropriate. However, some C&RS staff
expressed a reluctance for initiating condition reports due to unclear management
- -- ----- - ---
expectations (Section R7 .1 ).
2
Report Details
. IV. Plant Support
R1
- Status of Radiological Protection and Chemistry (RP&C) Controls
R1 .1 Implementation of the Radiological Posting Program: Failure to Post a High Radiation
Area
a.
Inspection Scope (IP 83750)
b.
The inspectors reviewed the circumstances surrounding a high radiation area (HRA)
incident in which an HRA posting was inappropriately removed, including the applicable
procedures and survey data. The inspectors also conducted walkdowns throughout the
radiologically controlled areas (RCAs) and interviewed Chemical and Radiological
Services (C&RS) personnel regarding the radiological posting program.
Observations and Findings
At 4:00 a.m. on September 16, 1997, C&RS staff replaced an HRA posting and rope
barricade in the clean waste filter transfer room (Room 708), which had been
inappropriately taken down. The current radiological conditions, as documented on the
status sheet, confirmed that an HRA existed in Room 708 near the waste filter storage
box. The status sheet indicated radiation levels of 500 millirem per hour at 30
centimeters from the storage box. The C&RS staff later initiated a condition report, and
further evaluation indicated that this HRA posting had not been in place since
approximately 11 :30 a.m. on September 15, 1997 (See Section R4.1 ).
10 CFR 20.1902(b) requires that the licensee post each high radiation area with a
conspicuous sign bearing the radiation symbol and the words "CAUTION, HIGH
RADIATION AREA" or "DANGER, HIGH RADIATION AREA". Pursuant to 10 CFR
20.1003 a high radiation area means an area, accessible to individuals, in which radiation
levels could result in an individual receiving a dose equivalent in excess of 100 millirem in
1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> at 30 centimeters from the radiation source or from any surface that the radiation
penetrates. Therefore, the failure to post the HRA in Room 708 for approximately 16
hours was a violation of 10 CFR 20.1902(b) (VIO 50-255/97015-01 ).
During walkdowns throughout the RCAs, the inspectors observed that, in general, the
radiological postings were appropriately established and accurately reflected current
radiological conditions as documented on the radiological area status sheets mounted at
the room entrances. However, the inspectors identified the following instances where the
postings were either inappropriately established or secured:
one. end of the HRA rope barricade for the spent resin transfer pipe from T-100 to
T-109 was tucked into a door jam rather than being securely fastened,
3
c.
a posting above the T-109 room utilizing the standard radiation three-bladed design
with magenta/yellow colors, stated "Do Not Enter" with no radiological information,
on the refuel floor, the rope barricade and the boundary tape which designated a
contamination area (CA) did not coincide, as the rope barricade encompassed a
larger area which included plant components which were not within the taped area
and were not considered as being within the CA, and
other postings in the Auxiliary Building were secured with duct tape or fasteners
which did not have sufficient strength to secure the posting under work conditions.
C&RS staff promptly and appropriately addressed the first three posting issues after they
were identified by the inspectors. However, the lack of secure postings was a repetitive
issue, as recent condition reports (CRs 96-1283, -1346, and 97-1481, -1598, -1599)
documented that rope barricades were down due to the failure of the duct tape and hooks
to secure these postings. The C&RS management was aware of this issue and planned
to upgrade the materieis used to establish and secure radiological postings.
Station procedure HP 2.20, "Radiation Safety Area Posting", requires that contamination
areas be posted with the words "Caution Contamination Area" on either boundary tape or
barricades (ropes). Discussions with C&RS staff indicated that boundary tape was
.
primarily used to establish the required CA boundary and that the rope barricades were
generally used to prevent inadvertent entrance into these areas. Therefore, plant staff
regarded the boundary tape as the delineation of the actual CA, and the rope barricade
was considered additional information .
Members of C&RS indicated that the lack of regard for a rope barricade as a radiological
posting/boundary may have contributed to recent instances in which site staff did not
replace posted rope gates at several CAs throughout the facility (CRs 97-1600, -1606).
Several C&RS staff stated that it was not uncommon to find CA rope barricades down.
The inspectors discussed with C&RS supervision whether the current tape/rope practice
caused confusion amongst plant personnel as to the adual CA boundary, and whether
this practice contributed to a lack of respect for other rope barricades within the plant.
The C&RS supervision staff indicated that the current practice would be reviewed.
Conclusions
Overall, postings in the plant were consistent with the radiological conditions documented
on the status sheets mounted outside the rooms. However, one violation was identified
for the failure to post an HRA, and several postings were either inconsistent or lacked the
proper materiel to maintain the postings securely in place. The inspectors also
questioned whether the CA posting practice caused confusion amongst the plant staff
and contributed to several recent instances where rope barricades were found down at
- several CAs within the plant.
4
R1 .2 Failure to Perform Radiological Surveys and Failure to Forward Survey Data for Review
a.
Inspection Scope (IP 83750)
The inspectors reviewed applicable procedures and survey data, including the surveys
conducted in support of clean waste filter transfer activities in Room 708. In addition, the
inspectors interviewed C&RS staff regarding the implementation of the survey program.
b.
Observations and Findings
The C&RS staff post a radiological area status sheet outside rooms to inform plant
personnel of current radiological conditions. Health physics technicians (HPTs) conduct
surveys and update thes*e status sheets as plant conditions warrant. Plant procedure HP
2.14, "Radiological Survey Requirements", step 6.1.1 requires that surveys be
documented on the appropriate form and that logbooks should not be used to officially
document survey information. The non-routine survey results should be documented on
a radiological survey sheet. Procedure HP 2.17, step 5.5 6, "Performance of Radiation
and Contamination Surveys", requires that this survey data be forwarded to the cognizant
duty health physicist (HP) for review and signature. The updated status sheets were to
be posted within the same shift that the new survey was completed.
Although the inspectors noted that most of the routine sur'Vey data and status sheets
followed this sequence, the radiological surveys conducted in support of filter transfer
activities in the clean waste filter transfer room (Room 708) did not always follow
procedural requirements or C&RS expectations. Specifically, the recent history of the
radiological surveys for these activities was as follows:
On September 8, 1997, a radiation survey was conducted after a waste filter
transfer in Room 708 and reviewed.. The status sheet was updated to show the
new dose rates and the CA, but a contamination survey to determine the extent
and magnitude of the contamination in the posted CA was not conducted.
On September 9, 1997, a radiation and contamination survey was conducted after
a waste filter was transferred to the filter storage box (black box). The data was
reviewed by the duty HP, but the status sheet was not updated until the next day.
On September 10, 1997, a radiation survey was performed after a third filter was
transferred to the black box, and the status sheet was updated. However, C&RS
staff did not forward the survey data to the duty HP for the required review, and a
survey was not conducted to determine the contamination levels in the posted CA.
On September 13, 1997, C&RS staff placed a rope barricade with a CA posting at
the Room 708 entrance per the request of the operations staff, b_ut this CA posting
was never noted on the status sheet.
5
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On September 15, 19971 the status sheet did not have contamination data for the
posted CA in Room 708; therefore, there was no data to inform the radwaste
handlers regarding contamination levels.
The status sheet was updated on September 16, 1997, to support removal of the
CA posting after the decontamination of Room 708. This survey data Was not
documented on a survey form nor was the updated status sheet forwarded to the
duty HP for review and signature (the survey was documented in the health physics
logbook, although procedure HP 2.14 states that logbooks should not be used to
officially document survey information).
Although station procedures do not require that staff document survey data on the
radiological survey stieets, procedure HP 2.17 requires that completed survey
documentation be forwarded to the cognizant duty HP for review and signature.
Therefore, when C&RS staff updated the status sheet based on survey results, this
updated status sheet was the survey documentation which was required to be forwarded
and reviewed by the duty HP. Technical Specification (TS) 6.4.1 requires, in part, that
procedures be implemented covering activities recommended in Regulatory Guide 1.33,
Appendix A. Regulatory Guide 1.33, Appendix A recommends that procedures covering
radiation surveys be implemented. The failure of the C&RS staff to forward, review, and
sign the completed survey documentation, as required by procedure HP 2.17, for Room
708 on September 10 and 16, 1997, are examples of a violation of TS 6.4.1 (VIO 50-255-
97015-03a).
Procedure No. HP 2.14, "Radiological Survey Requirements", step 6.1.3, requires that
plant personnel perform contamination surveys to locate and post and/or verify CA
boundaries, to determine the extent and magnitude of radioactive contamination, and to -
verify that contamination is properly controlled. As described above, C&RS staff did not
perform a contamination survey after the clean waste filter transfers were completed in
Room 708 on September 10, 1997. Therefore, there was no data regarding the extent
and magnitude of contamination in the area available to the radwaste handlers prior to
the decontamination on September 15, 1997. After the decontamination the gross
massllin survey indicated 60,000 - 80,000 disintegrations per minute (dpm) per frisker
probe face area on each massllin. This failure to perform a survey, as required by
procedure HP 2.17, to determine the extent and magnitude of contamination after the
completion of the clean waste filter transfers is another example of a violation of TS 6.4.1
(VIO 50-255/97015-03b).
On September 15, 1997, sometime after 11 :30 a.m. the HRA posting in Room 708 was
taken down. Three HPTs observed the downed HRA posting, but only the last individual
replaced the posting at 4:00 a.m. on September 16, 1997. In each case, these HPTs
failed to conduct a survey to verify the correct status of the HRA posting. Available
radiological data indicated that the posting should have been up, and procedure HP
-- --------
2.14, step 6.1.2, requires that plant personnel perform radiation surveys to locate and
post and/or verify radiation area boundaries. The failure of the C&RS staff to perform
radiation surveys, as-required by procedure HP 2.14, of Room 708 to verify the validity of
the downed HRA posting or the position of the replaced HRA posting on September 15
6
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and 16, 1997, was a third example of a violation of TS 6.4.1 (VIO 50-255/97015-03c)
(See Section R4.1 ).
c.
Conclusions
The C&RS staff generally conducted routine radiological surveys in accordance with
station procedures, and the surveys were adequate to inform workers of radiological
conditions. Three examples of a TS violation were identified regarding the failure to
perform radiation and contamination surveys and the failure of C&RS staff to forward
survey data to the duty HP for review and signature as required by procedures.
R4
Staff Knowledge and Performance in RP&C
R4.1 Poor Health Physics Technician Performance
a.
Inspection Scope (IP 83750)
The inspectors reviewed an incident in which an HPT entered an HRA in the clean waste
filter transfer room (Room 708) without being aware of the dose rates. This review
included an evaluation of dosimetry and survey data and the condition report (C-PAL-97-
1291) root cause evaluation associated with this incident. The inspectors also
interviewed C&RS staff regarding the work activities conducted in Room 708, with an
emphasis on the HRA posting incident and the performance of the C&RS staff.
b.
Observations and Findings
On the morning of September 15,.1997, two radwaste handlers performed a
decontamination of Room 708. Although there was no contamination information on the
status sheet (Section R1 .2), the workers were briefed on the dose rates and were told
that the contamination levels were approximately 2,000-3,000 dpm. The workers stated
that the HRA posting was in place by the waste filter storage box (black box) when they
arrived at Room 708 and that they did not enter the HRA (which was not allowed under
their radiation work permit, RWP P970011). They further stated that they did not remove
the HRA posting but that they mopped under the rope barricade to clean the area around
the black box. Data obtained from the computer electronic dosimetry (ED) system
showed that the highest dose rate experienced by the workers was 69 millirem per hour
(mrem/h), indicating that no HRA entries occurred. This ED data was also consistent with
the status sheet which documented that dose rates at the HRA boundary were 70
mrem/h. The workers left the room at approximately 11 :30 a.m. on September 15, 1997.
Early in the afternoon of September 15, 1997, an HPT entered Room 708 to conduct a
gross massllin survey. The HPT stated that neither the CA barricade at the room
entrance nor the HRA posting at the black box were in pla~. The status sheet showed
- --
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the presence of an HRA around the black box, with levels of 900 and 500 mrem/h at the
box and at one foot, respectively. Because this individual was unaware of the recent
history of this room and because the posted barricades were down, the HPT assumed
7
that the filters had been removed from the black box and the room had been
decontaminated. The HPT did not have a radiation dose rate meter and did not review
the status sheet to become aware of the radiological conditions prior to entering the
room. The HPT also did not review the black box inventory board which was mounted on
the inside wall next to the Room 708 entrance. This inventory board indicated that there
were 4 filters in the black box, one of which was reading 7 Roengtens per hour (R/h) on
contact and 2R/h at 1 foot.
The HPT then performed a contamination survey of Room 708, during w.hich he
approached the black box and received a dose rate alarm on the ED (the dose rate alarm
was set at 80 mrem/h). The HPT assumed that there was a hot spot on the box and did
not consider that he was in an HRA: The HPT completed the survey, left the room, and *
analyzed the massllins. When the HPT exited the RCA, the ED computer instructed him
to contact the HP desk crewleader and printed out a report which stated that the
maximum dose rate he encountered was 128 mrem/h. Since the HPT was a member of
the C&RS staff and he knew the reason for the ED alarm, he did not believe it was
necessary to inform the crewleader. The HPT did not recall reviewing the ED alarm
printout and did not return to Room 708 with a radiation dose rate meter to evaluate the
validity of the ED alarm.
- Technical Specification 6.7.1 requires, in part, that entries by any individual or groups of
individuals permitted to enter HRAs with an alarming ED shall be made after the dose
rate levels in the area have been established and personnel are aware of them or when
qualified personnel have radiation dose rate monitoring devices to conduct radiation
surveillances. The failure of the HPT to have a dose rate meter or be aware of the dose
rate levels prior to entering the HRA in Room 708 was a violation of TS 6.7.1 (VIO 50-
255/97015-02).
During an Auxiliary Building materiel inspection walkdown later that day, a senior HPT
(SHPT) on the "C" shift observed the condition of Room 708. This individual was also
unclear regarding any recent work conducted in Room 708, but knew that the black box
was generally in an HRA. Although the SHPT did not enter the room, he observed that;
(1) the contamination rope barricade at the entrance was down, (2) cleaning materials
were stored within the CA boundary, and (3) the HRA rope barricade was neatly coiled
around the stanchion. This SHPT also did not review the status sheet or the black box
inventory but rather considered that plant personnel were in the process of cleaning the
room, and the misplaced HRA posting was regarded a housekeeping issue. The SHPT
replaced the CA rope barricade at the room entrance and completed the materiel
walkdown. Later, this HPT documented the condition of Room 708 on the Auxiliary
Building Walkdown form, which included a question as to whether the downed HRA
posting was proper. However, this individual did not document the downed HRA posting
in the health physics logbook, did not initiate a condition report without supervisory
prompting (See Section R7 .1 ), and did not return to Room 708 with a survey m~ter to
verify the validity of the questionable de-posted HRA.
At 4:00 a.m. on the "A" shift of September 16, 1997, a SHPT on routine rounds observed
that the HRA was not posted and replaced the posting. Although this SHPT reviewed the
8
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status sheet to verify the proper status of the HRA posting, he also did not return to
Room 708 with a radiation survey meter to verify that the HRA posting was now in the
proper position and did not initiate a condition report (See Section R7.1 ).
The HRA in the Room 708 was not posted from approximately 11 :30 a.m. on
September 15 to 4:00 a.m. on September 16, 1997, which was a violation of 10 CFR
20 .. 1902(b) (See Section R1 .1 ). In addition, the failure to perform surveys to evaluate the
downed HRA posting or to verify the position of the boundary was a TS violation (See
Section R2.1 ).
The inspectors discussed the HPT performance with C&RS management and stated that
the C&RS staff appeared to conduct-the routine rounds with a narrow focus on the
specific task at hand, which contributed to the weak HPT performance in this HRA
incident, and that this narrow focus was partially due to the lack of a clear communication
from the C&RS supervision regarding their expectations from these activities. In addition,
the inspectors questioned the practice of HPTs conducting rounds throughout the
Auxiliary Building without a survey meter, as this practice might contribute to the narrow
focus of the C&RS staff. C&RS supervision indicated that this practice would be
reviewed and that expectations for HPT performance on rounds would be clearly
communicated to the staff.
The failure of experienced HPTs to consider the available information {the Room 708
status sheet, the black box inventory, the ED alarm, and ED alarm report) to evaluate the
do~ned HRA posting was considered a weakness .
c.
Conclusions
One violation for failure to have a radiation dose rate meter or be aware of dose rate
levels prior to entering an HRA was identified. In addition, weaknesses were identified in
that experienced C&RS personnel: (1) did not sufficiently question a misplaced HRA
posting, (2) did not utilize the available radiological information to evaluate the downed
HRA posting, and (3) did not initiate a condition report without supervisory prompting.
The inspectors also noted the lack of a clear communication of management
expectations for some aspects of HPT performance may have contributed to the poor
HPT performance.
R5
Staff Training and Qualification in RP&C
R5.1 Health Physics Training for C&RS Staff. Radiation Workers. and General Employees
a.
Inspection Scope (IP 83750)
The inspectors reviewed several lesson plan outlines regarding health physics training for
C&RS staff and radiological safety training for general plant employees. In addition, the
inspectors reviewed HPT job performance measures and selected training records, and
interviewed training personnel.
9
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b.
Observations and Findings
Lesson plan outlines for training HPTs covered basic radiation protection topics,
regulatory requirements, significant industry and plant events, and included laboratory
exercises to afford practical hands-on training to C&RS staff. The HPT lesson plans also
incl_uded common problems, such as inadequate surveys and failure to follow procedure.
The lesson plan for general employee training (GET} included basic radiological
information to permit plant access and detailed radiation protection information to permit
individuals to function as radiation workers. For example, the GET presented the proper
response to alarming dosimetry and the prohibition against moving radiological
boundaries.
Although the lesson plans presented comprehensive information regarding radiation
protection issues and appropriate radiation worker practice, the inspectors noted several
minor inconsistencies between training materials and station procedures which may have
contributed to the problems which were identified regarding radiological postings and
surveys.
Inconsistencies regarding the lack of understanding or regard for CA rope barricades as
boundaries include:
Lesson plan RWT-G-1-00, Section 6.10, for radiation worker training did not include
either "Contamination Area" or "High Contamination Area" as types of radiological
postings.
Lesson plan HPl-07, Section H, did not list "Contamination Area" or "High
Contamination Area" as types of radiological signs.
The C&RS Job Performance Measures for radiologicar surveys (Duty Area 559)
states that contamination boundaries were marked off by "rope and tape, unless
the area does not permit both, or a Health Physics Technician maintains positive
control over the taped boundary.". Procedure HP 2.20, step 5:1.7, stated that
contamination areas may be identified with either boundary tape or barricades
(rope) bearing the words "Caution, Contamination Area".
Inconsistencies regarding the problems identified with radiological surveys include:
Lesson plan HPl-07 (Radiation Survey Techniques) Section B, stated that survey
data should be reviewed by supervisors. However, as noted in Section R1 .2, HP
2.17, step 5.5.6, requires that completed survey documentation be forwarded to the
Duty HP for review and signature.
Lesson plan HPl-LAB-01, Objective 5, described the use of rcidiological area status .. - ---- - --
-sheets-for survey data, but does not include the use of radiological survey sheets to
record survey data, as stated in HP 2.17, step 5.5.3 (the updating of status sheets
to solely docu_ment survey data contributed to the lack of duty HP review and
signature noted in Section R1 .2).
10
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--::.:='::":::.:-_.::..-::..-::...:...*- -* .....::.__ . ..:::::::.:___ .. ____ ==::-=:::.-. ___ ::.:=::.*:.-*:. --=:.
The inspectors discussed with C&RS management whether these minorinconsistencies
in training may have contributed to the problems identified in this report. C&RS
supervision indicated that inattention to detail between various station*documents had
been identified previously and that these training inconsistencies would be reviewed as
part of a larger initiative to address similar issues.
c.
Conclusions
The GET, radiation worker, and HPT training addressed radiological and radiation
protection issues. However, the inspectors noted several minor inconsistencies between
training materials and plant procedures regarding CAs and radiological surveys.
R7
Quality Assurance in RP&C Activities
R7.1 Implementation of the Corrective Action Program
a.
Inspection Scope (IP 83750)
The inspectors reviewed procedure No. 3.03, "Corrective Action Process", and the root
cause evaluation for condition report C-PAL-97-1291 regarding the HRA posting incident.
The inspectors also interviewed C&RS staff regarding the process for condition report
(CR) initiation, evaluation, and resolution.
b.
Observations and Findings
The licensee established a corrective action process to document, track progress,
evaluate, correct, report, and trend conditions adverse to quality, nuclear safety,
radiological safety or industrial safety. On September 16, 1997, the C&RS staff initiated a
CR for the misplaced HRA posting identified in the clean waste filter transfer room. As
the "C" shift HPT was the first individual to document that the HRA posting was
misplaced, he was instructed by the duty HP to initiate the CR. Due in part to past
problems with HRA postings (C-PALs 96-0170,-1283,-1346, 97-0781,-1137), the health
physics operations supervisor recommended that C-PAL-97-1291 receive Level II
significance, which required a root cause analysis and corrective action.
In accordance with procedure, the CR was submitted to the shift supervisor, who made
appropriate operability and reportability determinations, and afterwards the CR was
approved as Level II by the Condition Review Group (CRG). The CRG ensured that the
operability and reportability determinations were documented, and then determined that
the Maintenance Rule was not applicable to the CR. Within three days of CR initiation,
the Corrective Action Review Board (CARB) concurred with the previous determinations,
assigned the C&RS Assessor as the condition review team leader (CRTL) to conduct the
required root cause evaluation and established a completion date for th_e _ey_aJu;:ition. __ _
The C&RS assessor conducted the root cause evaluation for CR C-PAL-97-1291 and
completed the required Trend Coding Form. The evaluation consisted of interviews with
C&RS staff and a review of ED data, surveys, status sheets, RWPs, and the health
11
physics logbook. The CRTL determined that HRA posting and entry violations had
occurred, that several inappropriate actions and human errors occurred, that there was a
lack of documentation in the health physics logbook, and that the HPTs did not promptly
initiate a CR. The root causes for the problems were considered to be: (1) individual
performance issues, (2) lack of a questioning, self-checking attitude, (3) professional
mi~judgement, and (4) lack of sensitivity to HRA postings.
The CRTL developed several corrective actions during the root cause evaluation. The
recommended actions included; (1) a walkdown to verify that all status sheets were
consistent with current room conditions, (2) appropriate discipline for the individuals
involved, and (3) a determination of NRC reportability.
The C-PAL-97-1291 root cause evaluation was presented to a Management Review
Board (MRB) on October 14, 1997. The MRB added the following corrective actions; a
stand down meeting with C&RS staff to communicate standards and expectations,
improvement of the C&RS Management Observation Program, and a self-assessment of
the C&RS Management Observation Program. The root cause evaluation and the
corrective action recommendations were completed by the established due date. The
inspector determined that plant personnel effectively implemented the corrective action
process in response to C-PAL-97-1291.
Although plant staff effectively evaluated and tracked CRs after initiation and assignment,
members of the C&RS staff expressed some reluctance to initiate CRs. The staff
indicated that they were unsure of the significance threshold for CR initiation, that they
did not clearly understand CR expectations, and that they thought the CR might be
considered too minor. The inspectors questioned the C&RS management as to whether
the CR expectations had been clearly communicated and understood by C&RS staff.
C&RS supervision stated that their expectations for initiating a CR would be
communicated to the staff.
c.
Conclusions
Plant personnel effectively implemented the corrective action process in accordance with
station procedure. The root cause evaluation conducted in response to the HRA posting
incident identified significant problems within C&RS, and the recommended corrective
actions appeared appropriate for the significance of the event. The C&RS staff
expressed some reluctance to initiate CRs due to unclear supervisory expectations.
X1
Exit Meeting Summary
The inspectors presented the inspection findings to members of licensee management during
an exit meeting on November 7, 1997. Plant personnel did not indicate that any materials.
examined during the inspection should be considered proprietary.
12
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PARTIAL LIST OF PERSONS CONTACTED
Licensee
M. Banks, C&RS Manager
W. Dooli~le, Duty Health Physics Supervisor
M. Menucci, C&RS Assessor
T. Palmisano, Site Vice President and General Manager
C. Plachta, Health Physics Operations Supervisor
B. Fuller, Acting Resident Inspector, Palisades
INSPECTION PROCEDURE USED
IP 83750, "Occupational Radiation Exposure"
LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED
Opened
50-255/97015-01 VIO
Failure to post the high radiation area in the Clean Waste Filter
Transfer Room
50-255/97015-02 VIO
Failure to be aware of dose rate levels prior to entry into a high
radiation area
50-255/97015-03 VIO
Failure to comply with radiological survey requirements
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CA
C&RS
CR
CRTL
dpm
HPT
IP
SHPT
TS
ACRONYMS USED
Contamination Area
Corrective Action Review Board
Chemical and Radiological Services
Condition Report
Condition Review Group
Condition Review Team Leader
disintegrations per minute
Electronic Dosimetry
General Employee Training
Health Physicist
Health Physics Technician
Inspection Procedure
Management Review Board
Radiologically Controlled Area
Radiation Work Permit
Senior Health Physics Technician
Technical Specifications
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LISTING OF DOCUMENTS REVIEWED
Technical Specifications Sections 6.4 - Procedures; and 6.7 - High Radiation Area
Palisades Nuclear Plant (PNP) Health Physics Procedure No. HP 2.14, Revision 17,
"Radiological Survey Requirements".
PNP Procedure No. HP 2.17, Revision 13, "Performance of Radiation and Contamination
Surveys".
PNP Procedure No. HP 2 .20, Revision 10, "Radiation Safety Area Posting".
PNP Administrative Procedure No. 7.13, Revision 6, "Radiation Controlled Area Access".
PNP Administrative Procedure No. 3.03, Revision 18, "Corrective Action Process".
Radiation Work Permits P970001, P970010, P970011
Condition Reports, C-PAL-96-0170, 96-1283, 96-1346, 97-0781, 97-1137, 97-1291, 97-1597,
97-1598, 97-1599, 97-1600, 97-1606.
Lesson Plan HPl-01, Health Physics I, Purposes and Definitions
Lesson Plan HPl-05, Health Physics I, Dosimetry
Lesson Plan HPl-08, Health Physics II, Standards and Regulations
Lesson Plan HPl-07, Health Physics I, Radiation Survey Techniques
Lesson Plans HPll-LAB-02, Radiological Seminar and Contamination Control
Lesson Plan HPl-LAB-01, Radiation Instruments and Surveys
Lesson Plan RWT-G-1-00, General Employee and Radiological Safety Training, Radiation
Worker Training-Generic
Lesson Plan PAT-G-1-07, General Employee and Radiological Safety Training, Radiological
Orientation
Course Description, Health Physics Orientation Training/N00301
Course Description, Health Physics 1/600470
Course Description, H~alth Physics 11/600473
- C&RS Job Performance Measures; Duty Area 559 - Radiological Surveys
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