ML20029E362
| ML20029E362 | |
| Person / Time | |
|---|---|
| Site: | Zion File:ZionSolutions icon.png |
| Issue date: | 05/12/1994 |
| From: | Tuetken R COMMONWEALTH EDISON CO. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| NUDOCS 9405180192 | |
| Download: ML20029E362 (7) | |
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Commonwealth Edison N1 Sh b Zion, Illinois 60099 Telephone 708 / 746-2084 May 12,1994 U. S. Nuclear Regulatory Commission Washington, D.C. 20555 Attention:
Document Control Desk
Subject:
Brent Clayton letter to R. Tuetken dated April 15,1994 transmitting Notice of Violation (NOV) in NRC Inspection Report 50-295(304)/94008.
NRC Docket Numbers 50-295 and 50-304 Enclosed is the Commonwealth Edison Company (CECO) response to the subject Notice of Violation (NOV). The NOV cites one Severity Level IV violation for an event where a contract radiation protection technician willfully violated established station radiological procedures (specifically, failing to verify dose rates during radiography exposures). Also included as attachment A is the stations response (explanation and corrective actions accomplished) to a incident involving an individual being allowed to take contaminated clothing offsite. This attachment is being provided as requested in the subject inspection report.
If you have any questions or require additional information, please contact Marcia Jackson, Regulatory Performance Administrator at (708) 663-7287.
Very truly yours, b
R.P. Tuetken Site Vice President Zion Station RPT/sks cc:
J. B. Martin, Regional Administrator, Rlli C. Y. Shiraki, Project Manager, NRR J. D. Smith, Senior Resident, Zion Station o
e a
94o5180192 940512 PDR ADOCK 050oo295 O
PDR ZOSR/037-94.osr(9)
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RESPONSE TO NOTICE OF VIOLATION INSPECTION REPORT 50-295(304)l94008 3
VIOLATION: 295L304)l94008-01 During an NRC inspection conducted on March 14 through 23,1994, a violation of NRC requirements was identified. In accordance with the " General Statement of Policy and Procedure for NRC Enforcement Actions",10 CFR Part 2, Appendix C, the violation is listed below:
Technical Specification 6.2.2.A, states, in part, that radiation control procedures shall be prepared, implemented, and maintained.
Zion Administrative Procedure 600-06, " Radiological Controls for Radiography Activities",
requires that a radiation protection technician shall be in attendance during radiography activities to verify pre and post exposure dose rates.
Contrary to the above, on February 22,1994, a contract radiation protection technician left a radiography activity and did not verify dose rates in the exclusion area during the course of the subsequent radiography exposures.
This is a Severity Level IV Violation (Supplement IV).
REASONS FOR THE VIOLATIO_N Commonwealth Edison Company (CECO) acknowledges the violation. On February 22, 1994, a contract Radiation Protection Technician (RPT) willfully violated a station procedure while performing radiological job coverage of radiography. The radiography was being performed on safety injection valves located in the Unit 1 containment building. Zion
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Administrative Procedure (ZAP) 600-06 was in place to provide guidance on the necessary steps required to ensure that the appropriate radiological controls were applied.
A pre-job meeting was conducted, and the radiography activities were discussed with the individuals involved. The RPT assigned to cover these activities was briefed on the job scope, and indicated to a health physicist that he was fully cognizant of the procedure requirements. The work crew reported to the containment building, where the RPT established radiological boundaries, and coordinated a brief exposure of the Iridium-192 radiography source to enable the RPT to verify the boundaries were established appropriately. The RPT ti a requested that the radiographers contact him via telephone if they required further assistance. No further contact took place between the RPT and the radiographers.
ZAP 600-06 requires the performance of e verification survey to ensure that the radiography source has been properly retracted to the shielded position (after an exposure) prior to retrieving the radiographic film cassette, adjusting the guide tube, moving the source, or any other similar activities. The verification surveys were not performed by the RPT in attendance, but were performed by the radiographers (required by the radiographers ZOSR/037-94.osr(3)
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RESPONSE TO NOTICE OF VIOLATION INSPECTION REPORT 50-295(304)l94008 REASONS FOR THE VIOLATION (Continued) procedure). The omission of the verification surveys was not in accordance with the survey requirements stated in ZAP 600-06, and subsequently is in violation of Technical Specification 6.2.2.A, which requires that radiation control procedures shall be prepared, implemented, and maintained.
When questioned, the RPT stated that he was aware of the procedural requirements, and that he was provided adequate time to review the procedure. The RPT stated that he did not perform the required steps, and that he was not required to perform radiography coverage in the same manner at other sites, in addition, the RPT stated that he did not receive any notification from the radiographers that his assistance was required, which conflicted with the radiographer interviews (which stated that multiple attempts were made to contact the RPT). The RPT was asked if he deliberately ignored the procedural requirements of ZAP 600-06, and he responded "yes" Therein lies the willful violation of a station procedure.
The root cause of this event was a human performance deficiency, specifically, the omission of the appropriate surveys due to poor judgement on the part of the RPT. The RPT mistakenly determined that the survey performed by the radiographers was sufficient, and an additional survey oy a RPT was not necessary. The investigation determined that there-were no programmatic weaknesses, that the clarity and content of the procedural guidance was comprehensive, and that this was an isolated incident of poor judgement by this RPT only.
CORRECTIVE STEPS TAKEN AND RESULTS ACHIEVED The RPT was interviewed, and based on the willful nature of his actions, the RPT's employment was immediately terminated.
Radiation Protection Supervision (both contract and CECO supervision) involved in this incident received counseling on the need to maintain a high lovel of awareness and overview of radiological activities, and the importance of procedural compliance.
ZAP 600-06 and the supporting documentation (RWP, pre-job meeting notes, etc.) were reviewed for content, and found to be satisfactory. It is noteworthy to add that within the last year, ZAP 600-06 was revised and the administrative controls significantly upgraded.
ZOSR/037-94.osr(4)
RESPONSE TO NOTICE OF VIOLATION INSPECTION REPORT 50-295(304)/94008 CORRECTIVE STEPS TO BE TAKEN TO AVOID FURTHER VIOLATIONS The details of this event, the corrective actions, and a summary of the radiography procedural requirements were presented to all Radiation Protection personnel (both contracted and CECO employees).
DATE WilEN FULL COMPLIANCE WILL BE ACHIEVED Zion Station is in full complience. All corrective actions were implemented by March 4, 1994.
1 ZOSil/037-94.osr(5)
l ATTACHMENT A RESPONSE TO OPEN ITEM 50-295/94008-02, 50-304/94008-02 DESCRIPTION OF CONDITION On March 13,1994, a worker was allowed to leave the station in a paper suit carrying his bagged personal clothing. The worker had received multiple alarms on the guard house and radiologically posted area exit personnel monitors, and various follow-up surveys were performed to locate the origin of the monitor alarms. The worker's neck was decontaminated, and multiple manual frisks of the worker's clothing were performed, but the origin of the alarms was not determined. The Radiation Protection (RP) personnel determined that the origin of the alarms was an aggregate of very low level contamination present on the worker's clothing (below hand held detection equipment sensitivity). The worker was allowed to exit the station in a paper suit carrying the bagged clothing, of which one piece was later found to be contaminated.
On March 16,1994, the same worker had reported onsite, and prior to starting his work activities, received a whole body count. This worker stated that he had been receiving spurious alarms on the guard house exit personnel monitors. The whole body count indicated positive activity, and the source of the activity was determined to be a 70,000 dpm particle on the worker's pants. The particle was removed, and the worker proceeded to his normal worksite.
On the following morning, a RP representative interviewed the worker to determine the source of the particle. During the interview the worker indicated he had contaminated clothing at his motel. The RP representative requested permission from the worker to survey his motel room and contents therein. The survey was performed and three articles of clothing were found to be contaminated.
A dispute occurred during the survey of the worker's motel, which resulted in the RP representatives being asked to leave the worker's room, and the worker stated that he would not release the clothing to the RP representatives. The worker agreed to allow the RP representatives to continue the survey so long as a NRC representative was present.
That condition was met, and the survey was completed. The contaminated clothing was confiscated, and returned to the station for disposal. No contamination was detected within the worker's motel room or in his vehicle.
Although this event did not involve a violation of NRC requirements, weaknesses in the handling of the workers clothing were noted. The procedure governing the decontamination of a worker, and the release of clothing did not provide clear guidance on the most effective method to resolve this problem. Additionally, RP did not take proactive steps to alleviate the escalated situation which developed and led to the worker contacting the news media.
ZOSR/037-94.osr(6)
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ATTACHMENT A RESPONSE TO OPEN ITEM 50-295/94008-02, 50 304/94008-02 RESPONSEi A Problem identification Form (PlF) was written, and a root cause investigation was completed. Below is a summary of the inappropriate actions, immediate corrective actions, and long term corrective actions:
INAPPROPRIATE ACTIONS Two inappror,riate actions were identified. The first inappropriate action was that the radiological survey did not identify contamination on personal clothing. This inappropriate action occurred because specific guidance did not exist to address actions to take when hand held instrumentation surveys fail to locate the origin of a whole body monitor alarm.
The secono inappropriate action was that the individual was allowed to take contaminated personal clothing off site. This inappropriate action occurred when poor judgement was exercised in allowing the individual to pass clothing through the personnel exit monitor in a bag (which resulted in a less than optimal detection geometry).
IMMEDIATE CORRECTIVE ACTIONS A survey of the worker's motel room and his vehicle was performed on March 16,1994, to ensure no further spread of contamination had occurred. The confiscated clothing was passed through the guard house personnel monitors to determine if the clothing would alarm the monitors while bagged. Alarms occurred only when the bagged clothing was placed directly on the monitor detectors. An isotopic analysis of the contaminated clothing was performed to rule out other possible sources of contamination.
A survey of the worker's on site trailer was performed on March 16,1994, to ensure no further spread of contamination occurred.
The guard house personnel monitors were verified to be within calibration specifications. This action was also completed on March 16,1994.
ZOSR/037-94.osr(7)
ATTACHMENT A RESPONSE TO OFdN ITEM 50-295/94008-02, 50-304/94008-02 IMME.QlATE CORRECTIVE ACTIONS (Continued)
The individuals that demonstrated poor judgement in allowing contaminated clothing to be bagged and subsequently passed through the exit monitors have been counseled regarding this inappropriate practice.
The change area for decontamination pad personnel was moved to a more secluded area of the plant on March 18,1994, where the worker's clothing would be less likely to become contaminated.
Extensive surveys of the Auxiliary Building were conducted in routine and non routine areas to determine potential sources of contamination. These surveys and any associated decontamination activities were completed by April 22,1994.
LONG TERM CORRECTIVE ACTIONS Zion Radiation Procedure (ZRP) 5720-3, " Routine Personal External Contamination" will be revised to address the appropriate protocol for evaluating personnel contaminations. The revision will include specific actions to take when standard hand-held instrumentation does not detect contamination on clothing following whole body monitor alarms. This action will be completed by June 10,1994.
This event and all the ccrrective actions will be covered in the RPT annual retraining classes for 1994. The retraining willinclude procedure revisions, survey techniques, and lessons learned related to this event.
j ZOSR/037-94.osr(8)
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