ML18093A493

LER 87-014-00:on 871008,plastic Shoe Cover Found Wedged to Block Open Locked high-radiation Area Door Into Unit.Caused by Personnel Error.Door Closed & Locked as Required & Memo Issued Re Importance of Adhering to controls.W/871109 Ltr

ML18093A493
Person / Time
Site:	Salem
Issue date:	11/09/1987
From:	Pollack M, Zupko J Public Service Enterprise Group
To:	NRC OFFICE OF ADMINISTRATION & RESOURCES MANAGEMENT (ARM)
References
LER-87-014-01, LER-87-14-1, NUDOCS 8711170041
Download: ML18093A493 (5)

Text

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LICENSEE EVENT REPORT (LERI FACILITY NAME 111 I DOCKET NUMIEll 12) I P'AU& l;JI Salem Generatina station TITLE 141

- Unit 1 01s101010121112 1loF 014 Loss of Control of a Locked High Radiation Area Door Due To Personnel Error EVENT DATE 1111 LEA NUMlllER Ull REl'ORT DATE 171 DTHEll FACILITIEI INVOLVED Ill MONTH QAY VEAR YEAR. }(. SEOUENTIA~

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NO SUllMISSION DATE 1151 I I I On October 8, 1987 at 1030 hours0.0119 days <br />0.286 hours <br />0.0017 weeks <br />3.91915e-4 months <br /> a Radiation Protection Technician found a plastic shoe cover wedged to block open a locked High Radiation Area door into the Unit 1 bioshield in the area of No. 14 Reactor Coolant Pump {AB I. Upon discovery, the technician restored control of the door and reported the event. At 1225 hours0.0142 days <br />0.34 hours <br />0.00203 weeks <br />4.661125e-4 months <br /> the same day, the same HRA door was again found wedged open *via a plastic shoe cover.

The shoe cover was again removed and the event was reported. The root cause of these occurrences has been determined to be personnel error. Investigations have identified a number of individuals who had access to this area during the time period when the HRA door blockages occurred although it has not been determined who was directly involved. Memo's from the GM-SO have been issued informing station personnel of this *event and requesting assistance in determining all relevant facts associated with the HRA door blockage. To date, individuals have come f orw:ard to discuss the issue, although, no one has identified themselves or others as being responsible for the HRA door blockage. These discussions have shown that not all radiation workers are as aware of BRA key control procedures as they should be. The HRA key control program will be reviewed. Station personnel will be re-instructed as to the HRA programmatic requirements including the key control program. The training conducted by the Nuclear Training Center addressing the 03/12/87 HRA door blockage event {LER 272/87-002-00) will be reviewed by the GM-SO. Recommendations for appropriate changes will be addressed. A structured senior station management fact finding effort is currently in progress in an attempt to identify any individual(s) responsible and to resolve corrective actions.

8711170041 871109 PDR ADOCK 05000272 NllCFwm* s PDR --

LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating Station DOCKET NUMBER LER NUMBER PAGE Unit 1 5000272 87-014-00 2 of 4 PLANT AND SYSTEM IDENTIFICATION:

Westinghouse - Pressurized Water Reactor Energy Industry Identification System (EIIS) codes are identified in the text as {xx}

IDENTIFICATION OF OCCURRENCE:

Loss of Control of a Locked High Radiation Area Door Due To Personnel Error Event Date: 10/08/87 Report Date: 1~/09/87 This report was initiated by Incident Report No.87-383 CONDITIONS PRIOR TO OCCURRENCE:

Mode V Reactor Power 0% - Unit Load 0 MWe DESCRIPTION OF OCCURRENCE:

On October 8, 1987 at 1030 hours0.0119 days <br />0.286 hours <br />0.0017 weeks <br />3.91915e-4 months <br />, while making a routine inspection, a Radiation Protection Technician found a plastic shoe cover wedged to block open a locked High Radiation Area door into the Unit 1 bioshield in the area of No. 14 Reactor Coolant Pump {AB}. Upon discovery, the technician removed the shoe cover, restoring control of the door, and reported the event. At 1225 hours0.0142 days <br />0.34 hours <br />0.00203 weeks <br />4.661125e-4 months <br /> the same day, the same HRA door was again found wedged open by a plastic shoe cover.

The shoe cover was again removed and the event was reported.

APPARENT CAUSE OF OCCURRENCE:

The root cause of this occurrence has been determnined to be personnel error. The individual(s) involved apparently disregarded established procedures and their Radiation Worker Training.

ANALYSIS OF OCCURRENCE:

Access to HRA's is controlled to prevent personnel from unknowingly entering areas where excessive radiation dose could be accumulated.

The subject HRA contained general area radiation levels ranging from 5 mRem/hr to 200 mRem/hr. Contact radiation levels ranged from 50 mRem/hr to .5000 mRem/hr. Dosimetry reports for all personnel badged at Salem were examined to check for potential high exposures that could have resulted from uncontrolled access. No significant exposures were discovered. All indicated exposures were fifty (50) mrem or less.

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. LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating Station DOCKET NUMBER LER NUMBER PAGE

=U=n=i~t'---"1=---~~~~~~~~~~~~~---=5~0~0~0~2~7~2=-~~~~~8~7_-~00~1~4~--0-=-=-0~-~~~3'--'of 4 ANALYSIS OF OCCURRENCE: (cont'd)

Upon discovery, the door was closed and locked as required. This occurrence involved no undue risk to the health and safety of the public. However, because this occurrence involves a situation contrary to the requirements of the Technical Specifications, this event is reportable in accordance with the Code of Federal Regulations 10CFR 50.73(a) (2) (i) (B).

A similar occurrence involving the same High Radiation Area door occurred on March 12, 1987. Unit 1 LER 272/87-002-00 addresses that event.

CORRECTIVE ACTION:

An investigation was conducted to determine who had access to this area during the time period when the HRA door blockages occurred.

The computerized Personnel Radiation Exposure Monitoring System (PREMS}, Radiation Work Permits (RWPs), and the Security Containment access logs were used. Interviews with these individuals has not revealed anyone who might have defeated the locked HRA door.

The General Manager - Salem Operations issued a memo to all department managers addressing this event. It stresses the importance of adherence to radiological controls and emphasizes the responsibilities of radiation workers. The memo requires documented review by station personnel.

A letter, from the General Manager - Salem Operations to each of the individuals who had access to the area, was issued requesting the individual(s) involved in blocking open the HRA door to come forward. The intent is to determine why personnel violated good station radiation worker training practices and then to examine these reasons and implement programmatic corrections. Individuals have come forward to discuss the issue, although, no one has identified themselves or others as being responsible for the HRA door blockage.

Through these discussions, it has become apparent that not all radiation workers are as aware of the procedures for HRA key control as they should be.

A formal senior management fact f in~ing effort is being conducted which includes interviews with all personnel in the area at the time of the incident.

The HRA key control program will be reviewed. Station personnel will be re-instructed as to the HRA programmatic requirements including the key control program.

LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating Station DOCKET NUMBER LER NUMBER PAGE Unit 1 5000272 87-014-00 4 of 4 CORRECTIVE ACTION: (cont'd)

. The training conducted by the PSE&G Nuclear Training Center addressing the March 12, 1987 HRA door blockage event CLER 272/87-002-00) will be reviewed by the General Manager - Salem Operations. Recommendations for changes will be addressed and incorporated into appropriate training programs conducted by the Nuclear*Training Center.

G~kl:rf Salem Operations MJP:pc SORC Mtg.87-095

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PS~G Public Service Electric and Gas Company_ P.O. Box E Hancocks Bridge, New Jersey 08038 Salem Generating Station November 09, 1987 U. S. Nuclear Regulatory Com.i~ission Document Control Desk Washington, DC 20555

Dear Sir:

SALEM GENERATING STATION LICENSE NO. DPR-70 DOCKET NO. 50-272 UNIT NO. 1 LICENSEE EVENT REPORT 87-014-00 This Licensee Event Report is being submitted pursuant to the requirements of 10CFR 50.73(a) (2) (i) (B). This report is required within thirty (30) days of discovery.

Sincerely yours,

/l::id!t.

General Manager-Salem Operations MJP:pc Distribution The Ene1*gy People 95-2189 11 ., lv11 12-84