ML20006B436
| ML20006B436 | |
| Person / Time | |
|---|---|
| Site: | Crane  |
| Issue date: | 01/25/1990 |
| From: | Roche M GENERAL PUBLIC UTILITIES CORP. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| 4410-90-L-0009, 4410-90-L-9, NUDOCS 9002020168 | |
| Download: ML20006B436 (5) | |
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OPU Nucleer Corporation NggIgf Post Office Box 480 Route 441 South
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Middletown, Pennsylvanla 17057 0191 717 944 7621-1 TELEX 64 2300 Writer's Direct Olal Number:
l (717) 948-8400 January 25, 1990 4410-90-L-0009/0521P i
1 US Nuclear Regulatory Commission Washington, DC 20555 1
Attention: Document Control Desk Three Mile Island Nuclear Station, Unit 2 (TMI-2)
Operating License No. DPR-73 Docket No. 50-320 Inspection Report 89-13 s
Dear Sirs.
The subject Inspection Report identified a violation of 10 CFR 20.201(b) wherein an inaceouate survey resulted in an unplanned radiation exposure to a technician. Pursuant to the provisions of 10 CFR 2.201, the attachnent provides the GPU Nuclear msponse to the NRC Notice of Violation.
- Sincemly, 3h r
M. B. Roche Director, TMI-2 EDS/ emf cc:
W. T. Russell - Regional Aaministrator, Region I J. F. Stolz - Director, Plant Directorate I-4 L. H. Thonus - Project Manager, TMI Site F. I. Young - Senior Resioent Inspector, TMI
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ff0b GPU Nuclear Corporation is a subsidiary of the General Pubile Utilities Corporation
/hI 9002020168 900123 c
PDR ADOCK 05000320 0
ATTACHMENT 4410-90-L-0009 HOTICE OF VIQ_ ATION 10 CFR 20.201(b), reouires, in part, that each licensee shall make or cause to be made such surveys as may be necessary and reasonable to ensuIt compliance with the reouirements of 10 CFR Part 20, 10 0 R 20.201(a) cefires a survey, in part, as an evaluation of the radiation hazards incident to the presence of radioactive materials under a specific set of conditions. When appropriate, such an evaluation includes a physical survey of material and eouipnent and measurements of levels of radiation present.
Contrary to the above, at approximately 2:15 a.m. on November 28, 1989, inaceouate surveys were made to assure compliance with that part of 20.101 which limits radiation dose to individuals in restricted areas. Specifically, a hose end-plug fitting was removed from the reactor vessel and handled by two technicians without properly measuring the radiation dose from the end-plug.
This resulted in an unplanned radiation exposure to one of the technicians and in the inappropriate removal of contaminated material from the reactor vessel.
t This violation is categorized as a Severity Level IV problem (Supplement IV).
GPU NUQ. EAR RESPONSE GPU Nuclear concurs with the Notice of Violation as described above. As identified in Inspection Report 89-13, this violation occurred curing the removal of a tool from the TMI-2 Reactor Vessel.
Due to the Radiological Controls Technician's (RCT) failure to perform an adeouate radiological survey of a highly radioactive item (i.e., the end-plug) during removal from the Reactor Vessel, this resulted in an unplanned exposure to the hand of the RCT. Several immediate corrective actions were taken including:
1.
Restricting access of the RCT to Radiologically Controlled Areas (RCAs);
2.
Performance of a preliminary dose assessment to ensure an exposure in excess of the 10 CFR 20 limits had not occurred (the most probable cose to the skin of the right hand was less than 300 mrem); and 3.
Stopping work in the Reactor Building pending a review of the event and i
the implementation of appropriate corrective actions to prevent recurrence.
In the period following the event, GPU Nuclear management performeo an in-depth review of the event. In addition, several discussions were held with l
NRC personnel prior to the December 4,1989, enforcement conference, to describe the event and the corrective actions GPU Nuclear proposed to undertake prior to resuming work in the Reactor Building.
I As discussed at the enforcement conference, the following actions had been initiated by GPU Nuclear.
l ATTACHMENT
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4410-90-L-0009 A training program was instituted for radiological workers and supervisors entering the Reactor Building that included a review of the following:
o Their responsibilities in recognizing unsafe conditions in areas that have the potential for presence of uncontained fuel debris and/or core structural material; o
The immediate actions that should be taken if such material is ercountered; and o
A practical factors demonstration of technioues when such material is encountered.
This training program is reouired of all personnel prior to entry into the Reactor Building.
One-on-one management meetings were held with all Radiological Controls personnel to ensure that the proper level of awareness and vigilance exists conceming proper handling of material potentially containing fuel oebris.
In addition, a design review of tools and eouipment currently in use was performed to minimize " crud traps." Supervisors were counselled conceming their obligation to continually re-evaluate the professional cualifications of their personnel prior to task assignments based on technical knowledge, behavorial attitude, and fitness for duty. Further, the existing Management l
Off-Shif t Tour Program was modified to ensure that Reactor Building cleanliress is monitored on these tours. Finally, a Human Performance Evaluation System (HPES) review of the event was undertaken to determire if additional corrective actions were warranted.
In addition to the actions discussed above, Inspection Report 89-13 also listed certain NRC-identified program weaknesses which were discussed at the December 4,1989, enforcement conference. These weaknesses and GPU Nuclear's actions taken are provided on the attached table.
GPU Nuclear concluded on December 8,1989, that appropriate corrective actions had been implemented to prevent recurrence. On this basis, Reactor Building work was resumed.
In addition to the corrective actions noted above, disciplinary action was subseouently taken against the RCT-for failure to perform his work activities in accordance with procedures, training, and oualifications. Further, the HPES Report of this event was recently completed.
In general, the recommendations in this report have been addressed.
Recommendations not addressed by the corrective actions are being reviewed by the responsible departments to determire if further action is warranted. This review and implementation of any additional corrective actions should be accomplished by March 1990.
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TABLE I 4410-90-L-0009 ACTIONS TAKEN TO ADDRESS NRC IDENTIFIED PROGRAM WEAKNESSES SPECIFIC ACTIDNis) TAKEN STATUS NRC IDENTIFIED WEAKNESS The RCT stated that the background dose rate in the vicinity A revised ALARA review (890009) for defueling Completed 12-07-89.
cf where surveys were being made of the Peters tool and the and defueling support activities was issued to end-plup were 5 to 8 R/hr beta. It was not clear to the include more specific radiological control technician what an acceptable background dose rate is for practices and radiological survey requirements.
making such surveys. In discussions the inspectors had Guidance for approval authority at various regarding this with other RCTs. it appeared that there was background levels is provided. A memorandum (9200-89-022) was issued to give 9eneral a confusion among the RCTs what acceptable background levels guidance in assessing work site conditions.
One RCT said that acceptable background would be about are.
2-3 R/hr open window, and another said 1 R/hr open window would be acceptable. The licensee should modify procedures ta provide clear directions to RCTs as to what background levels are acceptable for survey work and what should be done when the specified levels are exceeded. Direction should be clarified for all types of future work where there is a potential for high background dose rates.
The end-plug was removed from the vessel without having A Rad Con Department SOM has been prepared Completed 12-0749.
received an adequate survey. Survey procedures for all providing guidelines to Rad Con personnel for types of future work should be upgraded to ensure that survey practices doring removal of equipment adequate surveys are performed. The procedures need to from the Reactor Vessel and when performing take into consideration the possibility of objects with very surveys in other areas of the plant where high beta to gamma ratios and the particular problems of fuel may be present.
s rveying objects with this type of contamination.
Procedures should clarify how surveys are to be made, for
' example open or closed window and survey distance. Where appropriate, special equipment should be specified.
The end-plug was bagged for removal from the work slot much
- 1. PCR to Defueling Operations procedure and I.
Completed 12-06-89.
more quickly than usual without receiving oral approval from implementing procedures and UWIs approved the RCT. The rapidity in which the end-plug was bagged may requiring positive RCT indication prior to have contributed to the inadequacy of the survey. The raising the horizontal section of tools or practice has been that the operators may remove objects from equipment above the level of the work platform.
the_ vessel ~unless the RCT tells them not to.
Licensee ALARA Review 890009 also has hold points
- included, procedures should be revised to require approval by RCT at critical points in the progress of each job. These critical 2.
Work crew meetings have been held with all 2.
Completed 12-08-89.
points should be designated for each type of future job and clearly communicated to workers and to the RCTs.
Rad Con personnel to re-emphasize that the RCT is responsible to assure that work activities are conducted in a radiologically safe manner, that the RCT possesses "stop work" authority (i.e., the decision to proceed is the responsibility of the RCT) and when the RCT becomes aware of conditions which are not consistent with the ALARA review and RWp requirements, corrective action should be taken, including "stop work."
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TABLE 1 4410-98-L-0009 ACTIONS TAKEN TO ADDRESS NRC IDENTIFIED PROGtAM WEAKNESSES SPECIFIC ILRC IDENTIFIED WEAKNESS ACTIONiS1 TAKEN STATUS The RCT handled the end-plug prior to performing an adequate.
The importance of' performing radiological.
- Completed 12-06-89.
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survey on it. While in this case the RCT may have thought surveys on objects before handling them has he performed an adequate survey..in actuality he did not.
been the subject of numerous instructions prior The licensee shoofd emphasize to the RCTs the importance of to this incident. The RCT involved in this performing radiological surveys on objects before handling incident had, in fact, signed a statement them.
indicating he had read an instruction to this effect shortly before this incident occurred.
Nonetheless, because of this incident all RCTs were again instructed on the importance of performing radioingical surveys on objects prior to handling them.
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