Text

Enforcement Conference Rept 50-333/90-12 on 900409.Major Areas Discussed:Findings of Insp Rept 50-333/90-12 & 900308 Incident Involving Personnel Contamination w/high-specific Activity Na-24
	ML20034B801
Person / Time
Site:	FitzPatrick
Issue date:	04/20/1990
From:	Oconnell P; NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	;
Shared Package
ML20034B797	List: ML20034B796; ML20034B801; ML20034C758;
References
	50-333-90-12-EC, NUDOCS 9005010025
	Download: ML20034B801 (38)
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U.S. NUCLEAR REGULATORY COMMISSION

REGION I

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Report No. 50 333/90-12

Docket No. 50 333

License No. DPR 59

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Licensee:

Power Authority of the State of New York

P.O. Box 41

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Lycoming, New York 13093

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Facility Name:

James A. FitzPatrick Nuclear Power Plant

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Meeting At: NRC Region I, King of Prussia, Pennsylvania

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Meeting Conducted: April 9, 1990

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Prepared By

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P. O'Connell, Radiation 4pecialist,

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Facilities Radiation Protection Section

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D. Ch4Waga, Radiation Specialist

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FacilitiesRadiationProtection$ection

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Approved by:

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W. Pasciak Section Chief facilities

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RadiationkrotectionSection

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Meeting Summary:

The NRC requested meeting was an Enforcement Conference held

W NRC Region 1, King of Prussia, Pennsylvania, on April 9, 1990.

The

The to)ics discussed durins the meeting related to an incident which oc/ pu

of the meeting was to discuss the findings of NRC Inspection No. 50-333 90 12.

curred on

March 1 1990, and involvec personnel contamination with high specific activity

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Sodium-$4(Na24).

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The meeting was attended by NRC and licensee representatives and lasted for

approximately four hours.

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Details

1.0 Participants

1.1 New York Power Authority

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R. Beedle, Vice President Nuclear Support

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J.Brons.ExecutiveVicekresident

W. Fernandez Resident Mana er

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R.Lauman,Dlrector,Boilin Water Reactor Operations and Maintenance

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R. Liseno, Superintendent o Power

S. Porter, Consultant Engineer

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J. Solini,porate Supervisory Radiological Engineer

G. Re Cor Health Physics General Supcrvisor

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G. Vargo, Radiological and Environmental Services Superintendent

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1.2 NRC Personnel

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R. Bellamy, Chief, facilities Radiological Safety and Safeguards Branch

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D.Chawaga,her,EnforcementSpecIalist

Radiation Specialist Facilities Radiation Protection Section

K. Christop

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R. Cooper, Deputy Director, Division of Radiation Safety and Safeguards

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W. Kane, Director, Division of Reactor Projects

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M.Knapp, Director {ManagerDivision of Radiation Safety and Safeguards

D. LaBarge, Projec

J. Linville,ief, Reactor Projects Section IB

Chief, Projects Branch 1

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G. Meyer, Ch

R. Nimitz Senior Radiation Specialist, Facilities Radiation Protection

SectIon

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P. O'Connell Radiation Specialist, Facilities Radiation Protection Section

W.Pasciak,dhief,FacilitiesRadiationProtectionSection

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W. Schmidt

S.Sherbinl,SeniorResidentInspectorSeniorRadiationSpeciallst,FacilitiesRadiationPro

FitzPatrick

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Section

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K. Smith, Regional Counsel

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2.0 Purpose

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The Enforcement Conference was held at the request of NRC Region I to

discuss the circumstances relatino to a Na-24 contamination incident which

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occurred on March 8 1990

The discussions at this meeting focused on the

adeguacyandeffectIveness. of the licensee's pre job planning for the work

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evolution, the circumstances surrounding the event,luation for the

the corrective actions

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taken and planned following the event, the dose eva

contaminated individual

and the adequacy of the licensee's program to

conductnonroutineworkactivitiesinvolvingradioactivematerial,

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3.0 Licensee Presentation

The licensee summarized and discussed the investigation of the personnel

contamination incident which occurred on March 8, 1990. The following

matters were discussed:

the chronology of events associated with the contamination incident,

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the results of the licensee's evaluation of recent significant

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radiological events at the facility.

a summary of other events, evaluations, and indicators which assess

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the radiological control program,

an overview of radiological controls weaknesses, issues, and

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corrective actions, and

the results of the licensee's dose assessment for individuals who had

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been contaminated with Sodium-24.

The licensee's document entitled " Investigation and Analysis of Personnel

Radiation Exposure Incident," is attached.

The licensee stated that, with the exce) tion of some minor details, the

findings of NRC Inspection Report No. 5)-333/90 12 were accurate.

4.0 Concluding Statements

NRC Region I management stated that the licensee would be informed of the

need for and the nature of appropriate enforcement action relative to this

incident at a later time.

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Na 24 CONTAhilNATION EVENT

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ANALYSIS OF RECENT SIGNIFICANT

RADIOLOGICAL EVENTS AT FITZPATRICK

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REVIEW OF OTHER EVENTS, EVALUATIONS

AND INDICATORS TO ASSESS RADIOLOGICAL 3!

PROGRAhi

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OVERVIEW OF WEAKNESS, ISSUES AND

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CORRECTIVE ACTIONS-

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DOSE ASSESShiENT

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SUPPLEh1ENTARY INFORhiATION

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ENFORCEMENT CONFERENCE BRIEFING

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INVESTIGATION AND ANALYSIS OF MARCH 8,1990

RADIATION EXPOSURE EVENT

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Na 24 CONTAMINATION EVENT

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Chronology of Events for Na 24 Incident

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Causes, Weaknesses and Contributing Factor

2.0

ANALYSIS OF RECENT SIGNIFICANT RADIOLOGICAL EVENTS

AT FITZPATRICK

2.1

Adverse Radiological Events

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A. February 1987 Extremity Overexposure Incident

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B. June 1989 Significant Unplanned Exposure.

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Successful Radiological Events

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1988 Chemical Decontamination Program

B.1988 Core Spray Downcomer Repait

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REVIEW OF OTHER EVENTS, EVALUATIONS AND INDICATORS

TO ASSESS RADIOLOGICAL PROGRAM

3.1

Review of OA Audits /Surveillances (19871989)

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INPO Evaluation Review

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Radiological Incident Report System

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Perforraance Indicators

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RES Departmental Management Assessment

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NRC Inspections

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OVERVIEW OF WEAKNESSES,

ISSUES AND

CORRECTIVE

ACTIONS

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DOSE ASSESSMENT

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SUPPLEMENTARY INFORMATION

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1.0

Na 24 CONTAMINATION EVENT

1.1

CHRONOLOGY OF EVENTS FOR SODIUM 24

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CONTAMINATION INCIDENT

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March 7,1990

PM

Chief RES technician assigned to the Radiation Protection

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Office prepared a Special RWP for feedwater flow test.

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Protect,ve requirements included full protective clothing (PC),

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double gloves, portable RM 16.

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This technician had extensive experience in dealing

with liquid riources from nuclear medicine and

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recognized the need for protective requirements).

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March 8,1990

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ALARA group and RP technicians assigned to cover the test

discussed PC requirements and disagreed with previous PC

requirements. Requirements were downgraded with verbal

concurrence of ALARA Supervisor.

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(NOTE:

The chief RES technician cited above did not see

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the final version of the Special RWP for the test).

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Mock up was performed for Na 24 feedwater flow test with all

involved personnel, including technician P.

1300

ALARA pre plan meeting held for all personnel involved with

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the tea in:ludiug technician P. At no time during the meeting

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was'there any specific mention of the disposition of the Na 24

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source vial and cap.

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The Special RWP (90 0534S) for performing the test was

signed out.

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The leadman and technician P had their pre job briefing.

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The Test Engineer signed in on the RWP. He had the

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procedure and several other items needed in place before the

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actual work took place.

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1530

Others signed in on the RWP to obsetve the test performance -

from outside the work area.

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Two of the contractor specialists signed in on the RWP to set

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up for transfer of the source vial.

1545

Technician P entered on the RWP to measure dose rates, using

a teletector and ion chamber, during transfer of the source

from the cask to the mixing bottle. The protective clothing

requirements for the job included cotton boots, rubbers, lab

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coat, face shield, and surgeon's gloves. Technician P was

wearing cotton boots, rubber shoe covers, cotton glove liners

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and surgeon's gloves.

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De source vial was removed from the cask shield and

transferred to the lead holder by the contractor specialists. At

this time unnecessary personnel retreated due to the expected

high dose rates. The cap to the vial was removed and the

contents of the vial were transferred to the mixing bottle. . The -

vial was then returned to the lead vial holder.

1600

Technician P then surveyed the area (dose rates and smears)

and inappropriately replaced the cap to the vial. This was a

spontaneous action. One of the contractor specialists tried to

stop him, but was too late. This action was not observed by

other radiation protection personnel in the area.

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personnel outside the work area, and proceeded to the

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Radiation Protection Office hallway.

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The technician alarmed the whole body monitor at the RP

Office. Proceeded to frisk himself, contaminating the frisker~

probe. Two others (a technician and a supervisor) sustained

low level hand contamination from this action.

1625

Technician P was assisted by the shift technician, a chief .

technician, and a supervisor. The initial dose rate reading from

the technician's thumb was approximately 120 mrad /hr at one-

eighth inch using an RSO-50 ton chamber. Technician P was

decontaminated initially using soap and water.

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After continuous efforts at decontamination, a saline solution

was used to assist in isotopic exchange of the Na-24 for stable

sodium. The reading was 90 mrad /hr at one-eighth inch

(NOTE:

All subsequent ion chamber dose rate readings were

measured at 0.5 inches using an RO 5).

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After funhet soaking in the saline solution the dose rate

reading on the thumb was 48 mrad /hr. Subsequent to this

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time another decontamination effort was attempted using

potassium permanganate and sodium bisulfite.

2030

After further soaking in the saline solution the dose rate

reading on thumb was 40 mrad /hr.

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Dose rate reading on thumb was 34 mrad /hr.

Based on the

request of the technician he was released to go home with

cotton liners and surgeon gloves. He was given and bioassay

bottles with instructions for collection of urine for subsequent

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analysis. The Resident Manager and RES Superintendent

approved this action.

2105

PDP 11 form completed for initial skin dose assessment and

assigned dose at 480 mrem for the exposure interval.

2200

Further refm' ed preliminary integrated dose calculation estimate

of 4329 mrem by taking initially calculated skin dose rates in

accordance with PDP 11 and multiplying by mean life (1.44T).

March 9,1990

0232

Second stage dilution of Na 24 solution sample obtained and

0.1 ml was placed on a 47 mm millipore filter in a petti dish.

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Dose rate measurements were taken with an ion chamber and

counted on the HPGe for total activity to evaluate survey

instrument response.

0615

Dose rate reading on thumb was 22 mrad /hr.

0930

RES Superintendent and NRC Sr. Resident inspector made

telecon notification to R. Bellamy, NRC Region 1 Office about

the incident and preliminary dose calculations.'

1000

Dose rate reading on thumb was 18 mrad /hr.

1053

Bioassay sample counted, results negative.

1205

Dose rate reading on thumb was 14 mrad /hr.

1300

Whole body count of technician results were negative.

1330

Critique of Radiological incident Report 90-019. The

Superintendent of Power and NRC Sr. Resident Inspector

attended.

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'Ihe technicians assigned to the Na 24 test for March 10,1990

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were given extra training on the radiological significance of the

Na 24 source and the hazards involved

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Dose rate reading on thumb was 12 mrad /hr.

March 10,1990

0730

Dose rate reading on thumb was 4.5 mrad /hr.

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Pre job ALARA briefing for second Na 24 test.

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Mock up for second Na 24 test performed.

1230

Second Na 24 source transfer and test started.

1925

First stage dilution sample of sodium solution was obtained and

dose rated with an ion chamber and counted on the HPGe for

total activity.

March 11,1990

0730

Dose rate reading on thumb was 0.6 mrad /hr.

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NOTE: All subsequent readings were measured using a GM HP 210

pancake probe.

0700

Thumb contamination level was 2000 epm.

0800

Thumb contamination level was 500 cpm..

1245

Thumb contamination level was 380 cpm.

1600

Thumb contamination level was 300 cpm.-

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Based on review.of additional' data from the first dilution

sample of the second test it was determined that the apparent

exposure was in excess of 10 CFR 20.101 exposure limits. The

Resident Manager and Superintendent of Power were notified.-

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After independent verification of calculations, Occurrence

Report No. 90 57 was written and an informational call to the

NRC Resident Inspector was made.

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March 13,1990

0615

Dumb contamination level was less than 100 cpm,

RES Superintendent made informational call to W. Pasciak,

NRC Region I, concerning revised dose estimate,

March 14,1990

Consultant HP/Dosimetrist onsite to perfctm more detailed

skin dose calculations and to coordinate a rigorous calibration

of all appropriate survey instruments utiliziag a precise

geometry Na 24 standard,

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CAUSES, WEAKNESSES AND CONTRIBUTING FACTORS:

1.

Inadequate assessment of potential risks and reduction of

protective clothing. Initial RWP preparation had identified full

P.C.s to be worn. He ALARA review process reduced P.C.

requirements (due to convenience?) since they failed to consider

the potential for major contamination resulting from a spill, leak

or improper handling of the source. The ALARA process focused

on external exposure hazards only and contamination controls

were minimal. As a result the pre job briefing was inadequate.

2.

Personnel from the ALARA staff, properly qualified in radiation

protection procedures, prepared the ALARA review, developed

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the radiation work permit and provided the job coverage. This

produced a condition in which the normal independent review

relationship between the operational radiation protection group

and the ALARA group was bypassed and protective equipment

requirements were inappropriately reduced.

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Technician and staff training (at least for this individual) was

inadequate or ineffective in that personnel did not recognize the

contamination potential associated with this source and the high

beta dose rates that could be encountered.

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The technician providing job coverage acted outside his role as a-

monitor and assumed the role of a worker in handling the source

vial cap contrary to previous rehearsal in mockup training. The.

technician's protective clothing was inadequate for the activity that

he undertook.

5.

The technician aggravated the contamination event by failing to

obtain assistance from other radiation protection personnel when

extensive contamination was detected.on his person.

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Procedures for this evolution were weak in that there was

extensive cross referencing to vendor procedures and references to

radiological control requirements were _ vague (Example: "the

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evolution will be performed in accordance with radiation

protection procedures...").

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Due to the need for timely completion of this test concurrent with

pre-outage preparations, a task of major radiological significance

was undertaken with an already high workload, possibly reducing

the level of review.

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2.0

ANALYSIS OF RECENT SIGNIFICANT RADIOLOGICAL EVENTS

AT FITZPATRICK

2.1

ADVERSE RADIOLOGICAL EVENTS:

A.

EXTREMITY OVEREXPOSURE EVENT - February 1987

Inspection 50 333/87 07; LER 50 333/87-002-00

Summary:-

During the replacement of dry tubes in the reactor vessel, a contractor

reactor service technician received an extremity dose to the right hand of

29.6 rem while performing maintenance on a dry tube cutting tool.

During the cutting activity, a piece of the dry tube became trapped in

the cutting tool. . The dry tube fragment fell onto the refuel floor when

the tool was removed from the spent fuel pool. The exposure event

occurred when the reactor service technician picked up and handled the

irradiated dry tube fragment. The radiation protection technician

assigned to cover the job did not monitor dose rates as the tool was

being removed from the water. Instead, he assisted the workers by

holding a hose to rinse the tool as it was being removed from the pool.

Causes, Weaknesses and Contributing Factors:

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Multiple communications breakdowns

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Poorly defined authorities and responsibilities

(Technician acted more as worker not monitor)

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Failure to survey

4.

Failure to follow procedures - Workers violated RWP

requirements; workers did not conduct pre job briefing as

required; ARM local alarm was disconnected and not documented

as a jumper; leadman did not ensure worker compliance with

RWP requirements.

5.

Inadequate training

Personnel did not understand the magnitude

of the source associated with irradiated core components; staff

had little prior experience with this activity.

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Inadequate procedures

Hold points were not identified;

authorities and responsibilities were not clearly delineated;

response to alarms not addressed; ALARA review did not develop

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"what if" scenarios; high range extendable probe survey

instruments not specified.

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Failure to implement previously identified corrective actions.

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Inadequate equipment (tooling)

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Lack of supervisory oversight - No formal program for

management oversight of radiologically sensitive work,

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Inappropriate respect for radiological conditions and potential

consequences.

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FLOATING !!OT PARTICl2 . UNPLANNED EXPOSURE . June

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1989 Inspection 50 333/8913

Samatary:

During a spent fuel pool cleanup campaign two contractor personnel

received unplanned radiation exposures when a small high activity source

floated to the surface of the spent fuel pool.

Causes, Weaknesses and Contributing Factors:

1.

Inadequate control of materials introduced into the spent fuel

pool such that a floating hot particle source could develop.

2.

Inadequate equipment (installed area radiation monitors).

3.

Inadequate use of equipment (alarming dosimeters, portable

ARMS).

4.

Inadequate assessment of potential risks (i.e. potential for floating

hot particle).

Mitigating Factors:

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Prompt and conservative action by the radiation protection

technclan once high dose rates were detected (evacuation).

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SUCCESSFUL RADIOLOGICAL EVENTS AND ACTIVITIES

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1988 CHEMICAL DECONTAMINATION PROGRAM

Summary:

'In August September 1988 the FitzPatrick staff successfully completed

two chemical decontamination efforts using the I.OMI process: a-

demonstration program on portions of the RHR system and a larger

decontamination of the reactor water recirculation system and certain

attached piping. ' Ibis project involved the removal of over 61 Ci of

activity from plant systems and established record-setting

decontamination factors for dilute reagent chemical decontaminations.

During this project, there were no radiological incidents or aersonnel

contamination events despite the high potential for r> cess

enks and

transient dose rates produced during this process. 3e collective dose,

although somewhat higher than originally projected due to pre-

decontamination dose rates in the drywell, was controlled effectively and

the projected dose savings from the combined efforts was approximately

700 man rem in 1988.

One event, involving the incomplete cement solidification of LOMI lon

exchange resins, resulted in a civil penalty from the State of South

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C rolina and a corresponding Severity Level III violation from the NRC.

This event was subsequently determined to be generic in nature and

involved the adequacy of the NRC accepted Process Control Program for

the cement solidification of LOMI generated ion exchange resins.

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Successes:

1.

Significant risks associated with this activity were recognized

clearly at the beginning of the project.

2.

An interdisciplinary project team was assembled at the beginning

of the project and roles and responsibilities were clearly defined.

3.

Since the staff had no prior experience with this activity, the -

services of consultants with extensive experience in chemical-

decontamination were obtained to independently review vendor

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procedures and assist in monitoring vendor performance.

4.

An experienced member of the plant staff acted as the project

coordinator during the on site mobilization and operational phases

of the effort.

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Negatives:

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The radwaste solidification problems encountered in this project

were previously unknown to the Fitzpatrick Staff and were not

generally known in the industry. The existence of an NRC.

accepted Topical Report on the solidi 6 cation of LOMI wastes was

used by the radwaste solidi 6 cation vendor to provide assurance

to the Authority that solidification issues were addressed

adequately. Following discovery of this problem, the Authority

initiated a comprehensive corrective action program that included

research and development into the chemica mechanisms

responsible for incomplete solidi 6 cation and )roposed alternatives -

that are pending publication by the Electric Power Research

Institute.

- Analysis:

With the exception of the radwaste solidification issues, The Authority

demonstrated the ability to control non routine radiologically significant

tasks involving high activityE significant contamination stential (i.e.

greater than 1 uCi/100 cm ) and transient and potent:. ally high dose

rates.

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B.

CORE SPRAY DOWNCOMER REPAIR

Summary:

ISI performed during the 1988 refueling outage identified a

circumferential crack on a 4 inch Core Spray downcomer inside the

reactor vessel, approximately 6 feet above the top of active fuel. The

crack was not detected until fuel loading was approximately 2/3

complete. Due to the nature of the crack, the repair program required

dry hands-on welding to install a " clamshell" and restore structural

integrity.

This work involved relatively high dose rates (1 to 3 R)'hr general area

and 5 to 8 R/hr at contact. Contamination levels were 110 Ci/100

cm'. The initial dose projection for this effort was 25 man rem with a

potential for high airborne radioactivity during the weld repair.

The repair plan was successfully implemented using a collective dose of

only 11.5 man rem. There were no personnel contamination events and

no radiological incidents.

Successes:

1.

Significant risks associated with this activity were recognized

clearly at the beginning of the project.

2.

An interdisciplinary project team was assembled at the beginning

of the project and roles and responsibilities were clearly defined.

3.

Extensive mockup training was Mrformed to select qualified

welders, develop good work tec;miques and assess the adequacy of

personnel dosimetiy.

4.

A comprehensive ALARA package was developed to minimize

worker doses and engineering controls to minimize airborne

radioactivity were developed.

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REVIEW OF OTHER EVENTS, EVALUATIONS AND INDICATORS

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TO ASSESS RADIOLOGICAL PROGRAM

3.1

REVIEW OF QA AUDITS /SURVEILLANCES (19871989)

A.

A total of 20 audits and surveillances of which 10 involve

programmatic reviews (i.e. RE13, radiation protection, ODCM,

etc.), and 10 involve follow up to verify compliance with NRC

commitments or QA findings / recommendations.

B.

Total 11 findings

55 recommendations

C.

Majority of issues addressed procedural or programmatic

improvements:

None really involved RES personnel performance deficiencies

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One (1) recommended a reduction in number of contractors.

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One (1) recommended increased staff

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One (1) recommended clarification of what determines a

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radioiasic >

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One (1) recommended clarification of contents of a pre job

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briefing or pre shift briefing.

D.

Audit results demonstrate the existence of a strong defined

radiological program.

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INPO EVALUATION REVIEW

A.1986 Evaluatha

Strong ALARA program, job briefing, job

plaaa at mockup use.

Weakness in number and size of contaminated

area.

Weakness in response check of portable

instruments.

Weakness in radiological worker practices

(frisking, reach across boundaries).

(NOTE: not radiation protection technicians).

B.1988 Evaluation

Good practice (use of water shields).

Good practice (RWP lendman concept).

Weakness in solid radwaste final aggregate

measurement.

Weakness in insufficient trending of skin and

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Weakness in enforcing high standards of

radiological protection. (i.e responsibility of

radiation exposure goals, radiological work

practices of workers, personnel not held

accountable).

(NOTE: not radiation protection technician

practices).

C.1989 Evaluation

Weakness in calibration / daily check of certain

pieces of equipment.-

- Weakness in enforcing high standard of-

performance, (i.e. improper contamination

control by workers as seen by frisking,

reaching across boundaries, touching hand to

face)

issue of supervisor and radiation

. technicians not correcting.

O

. . . .

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_ . _

. _ _ _

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Weakness in final release of some clean

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waste.

.

(NOTE: nothing specifically on radiation

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protection technicians),

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3.3

RADIOLOGICAL INCIDENT REPORT SYSTEM

A. Donalttom

Site radiological incident report is generated,

reviewed, critiqued, etc. for the following:

1)

Unauthorized personnel exposures in excess of one,hundred and

ten percent of their admimstrative dose control guides.

2)

Internally deposited radioactive material in excess of 10%

Maximum Permissible Organ Burden (MPOB).

3)

Personnel contamination (sida or clothing) in excess of 10,000

8

d>m/100 cm ) (1,000 cpm) beta / gamma or 300 dpm/100 cm8

a pha.

4)

Personnel ex;xaure to airborne radioactivity levels exceeding 2

MPC Hours n any 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> period or 10 MPC Hours in any

consecutive seven day period.

5)

Personnel exposure to airborne concentrations exceeding 100%

Effective MPC.

6)

Loss or theft of licensed naterial.

O

7)

The ser d or r dia etiv surr e co t -i= tio i=

c

or

8

50,000 dpm

within a con /100 cm above surrounding contamination levels

taminated are.s without authorization or knowledge

of the RES Department.

8)

The spread of radioactive surface contamination in excess of

a

10,000 dpm/100 cm outside an established contaminated area.

9)

Uncontrolled or unplanned release of radioactivity contaminated

water.

10) Significant violations of established radiation protection

requirements.

11) Personnel entry into a radiation area or high radiation area

without proper dosimetry.

12) Personnel entry into a radiation area or high radiation area

without proper authorization.

13) Improper control of high radiation areas.

-O

14) Unauthorized or improper disposal of radioactive material.

i

'.-

.

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.

15) gological conditions. rating occurrences that result in unplanned de

16) Other reportable violations of federal regulations related to

radiation protection.

17) Excessive loss or misuse of dosimetry devices as defined in

plant dosimetry procedures.

18) Contaminated injuries requiring of-site medical treatment are

documented in accordance with the Site Emergency Plan.

19) Other as determined by management (ex: at' times any

contamination event involves RIR).

O-

O

,

11 .

,

-

.

B. Review of IM71M9 RIRs

Classi8eation

Departmental . Events

M

Personnel Exposure

, 2

0

Internal Exposure

1

Contamination 15K cpm

69

71

11

510K

12

6

1

10100K

20

11

4

> 100K

2

0

Hot Particle

0

36

16

MPC Hour Tracking

21

4

1

Spread / Unplanned Contamination

37

6

34

Dosimetry / Authorization

17

29

10

Regulation / Procedures

71

76

41

O

Total Department Events

252

303.

119

Total Personnel involved

294

90

Total RIRs

179

230

95

NOTE: 1) System tracks what, who (person and departments), classification -

causes not trended (weakness in system).

2) Responsible person or department sometimes unknown.

.

O

,

1

.'

.

C. Select Review of Events

1) 1987

three (3) incidents of 179 reviewed (1.7%) involved

inappropriate decisions by RES personnel

a) laborers allowed to work on drywell menanine with cotton

liners as protective clothing.

b) RES supervisor and technician entered drywell tanp area

without respiratory protection and received uptake.

c) Contract technician allowed craft workers to sign in on RWP

without alarming dosimeter as required by RWP,

,

2) 1988

Three (3) speci6c incidents of 230 reviewed (1.3%)

involved inappropriate decisions by RES personnel

a) Two (2) incidents where contract technicians not dressed as

workers while covering job that required respiratory,

b) RES technician wore rubber shoe covers instead of plastic

bootles while covering maintenance,

NOTE: Also had nine (9) other potential; however, insufficient

]-

time to research in detail. Of these nine (9), eight (8) involved-

contractor technicians, five (5) involved not taking air sample

when required, three (3) involved not properly signing' RWP,

3) 1989 - Nine (9) of 95 (9.5%) involved RES technicians.

a) Technician failed to take air sample required on RWP.

b) Contract technician failed to have controller sign RWP.

c)

Contract technician did not hold face to-face pre job briefing

(did on phone).

d) Contract RES supervisor downgraded Special RWP allowing

uptake.

e) Contract supervisor swallowing radioactive liquid.

f)

Contract technicians contaminated in area due to

insufficiently dressed, unfamiliar with area.

O

_ _ _ . _ _ _ _ _ _ _ _ _ - - - - - - _ - _ - - - - - -

'

.

..

.

g) Contract technician falsifying records.

8

b) _RES technician faued to have controller sign RWP.

()

RES technician cross-contaminated a hose.

NOTE: Six (6) of nine (9) involved contract technician.

O

_

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.

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3.4

PERFORMANCE INDICATORS

~

1987

1988

1989

Total Man res

Annual

940

785

377

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i

3 yr Average

801

712 .

695

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5 yr Average

894

833

713

Personnel Monitored

2,343

2,265

1,531

Radiation Work Permits

7,974

10,054

3,812

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Personnel Entries

77,500

116,597

39,361

-(

Contamination Events

299

337

82

f

Contamination as % of Entries

0.3856

0.294

0.21%

i

Radiological Incident Reports

179

230

95

RIRs as 4 of Entries

0.23%

0.1974

0.244

,

Positive Whole Body Count Level 1*

18

8

1

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Positive Whols Body Count Level 2*

0

1

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Solid Radwaste Volume (cubic meters)

4fa6

380

-263.5

Liquid Radwaste Volume (kgal)

779

1,151

89.6

,

Contaminated Area (t Restricted Area)

23.96 43.14

11.64-35.7% 11.254 16.2%

4

Service Hcurs

5,976

5,846

7,946

'

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' Note 1

INPO Defined Parameter Commenced in 1988. WBC results in 1987 based

on greater than 1% MPOB (sum).

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'3.5

RES DEPARTMENTAL MANAGEMENT ASSESSMENT (1989)

,

Background -August 1989, the OA Superintendent and Vice President Nuclear

Support were requested to conduct an assessment of the

.,'

Radiological Environmental Services Department, focusing on

3

4

management issues.

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8

This assessment involved interviews with 40 members of the'RES

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Department Staff.-

Results

~

- This audit documented a number of weaknesses in'the RES

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Department oreaah= don including:

}

A.

Management process de5clencies including the need to:

improve RIR critique feedback to RES technicians and line

staff, accountability of all personnel for radiological

-i

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performances.

B.

Organizational improvements needed to strengthen the-

operational radiation protection function, supervisory oversight

and use of senior union posidons (Chief Technicians).-

C.

Training im

,

technicians.provements needed for both supervisors and

The present union position that combines-

radiological nrotection and chemistry

needs to be ' split in order to improve / environmental functi

the depth ofinitial and

contim:ing training. ,

,-

-

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D. Extensive use of long-term contractors including contract

.

l

supervisors. Contractors and temporary employees are used

almost exclusively in some areas of significant radiological

risk (e.g. refuel floor). Permanent staff resources need to be-

l-

re decated to address this deficiency.

E.

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Communications between management and union. personnel

,

such as the lack-of regularly scheduled department meetings,

feedback on enforcement of radiation protection standards-

J

.(related to A above).

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3.6

NRC Inspections' (1M71M9)'

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A) Resident Inspector Reports (7)

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1). No problems

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2) One (1) discussed issue of lost stellite ball and proper response.

B) . Radiological Inspections (3).

'

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1) One (1) resulted in Level IV violation due to' missing radiological,

,

key, failure of a worker to follow RWP. and incomplete QA audit

'

on qualification.' A!!'other areas no problem. -

,

2) One (1) reactive inspection as a result lof overexposure.

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3) Overall Radiation Protection appraisal team inspection:

,

Good programs,'ALARA, plant dosimetry.,

)

-

Concern on technical proficiency of health physics staff.i

..

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Concern on understaffing, excessive overtime.

-

Concern on supervisory training.

-

Overall issues dealt with programs not performance.

-

1988

A) Resident Inspector Reports (6)

'

1) No problems -

-

B) Radiological Inspections ~(7)

- 1) One (1) reactive inspection resulted in a violation in response to

Barnwell waste shipment problem.

2) One (1) had no problem except open item on calibration of

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equipment.

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.

3) One (1) had no problem except open item on placing gate in

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potential high radiation area and another open item on control'of

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respir tors.

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4) Two (2) had no problems.

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5) One (1) had no problem except a violation on missing QA~ audit.-

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6) One'(1) had no problem except concern of use of contractors for:

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routine work and lack of proper work' space.

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7) Overall inspections focused on programmatic and not performance.

]

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-1989

L

' A.D Resident Inspector (7)

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.

1) No problemt

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2) One (1) discussed ingestion issue, unplanned exposure and

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observation of washer being handed across a contamination:

boundary.

H

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3) One (1) discussed high radiation area gate found unsecured

(mechanical problem).

~

' 4) One (1); discussed two (2) instances of improper work practice by

I & C personnel and Maintenance personnel.

5) One (1)-discussed issue of survey.information in HPCI Roomi

r

'before and during operation.

B. Radiological Inspections (5):

1) Three (3) had no problems.

2) One (1) was reactive inspection resulting from unplanned exposure.

Level IV violation issued due to inadequate survey.

-

Other weaknesses were malfunctioning bridge? ARM, no

-

supplemental. ARMS.used, two (2) workers not having' alarming

b

dosimetry, no set frequencies for performing survey, contractors

'

l

not checking pocket ' dosimeter, contamination control' observed

by workers (pass of material over boundary), ALARA review

not addressing potential hazard.

3) One (1) inspection had two (2) violations and one (1) unresolved.

Found area of plant with dose rate >100 mR/hr'(had changed

-

from last routine survey).

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Procedure violation on use of scintillation alpha. counter-

-

operation. -

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Noticed some RIRs did not document corrective action

-

although done- (did say no problems with managerial.

observation program).

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4.0

OVERVIEW WEAKNESSES, ISSUES AND CORRECTIVE ACTIONS-

4F

Organisation and Manage:nent Philosophy

A. Issues

i

1) Management philosophy of identifying and resolving problems and'

l

insisting on high performance standards is weak.-

2) RES organization does not provide balanced work requirements 1and.

responsibilities consequently, certain groups overworked.,

u

~

3) Several individuals have been performing same function for. years-

and, therefore, not learning from cross training. This may lead to

a " status-quo" mentality.

4) Communications between supervision and union personnel

i

expectations, how to improve standards of perfo.mance etc. has

L

been weak.

l

B. Corrective Action

'

O

1) New RES Superintendent placed in 1989.

2) Organizational improvements / rotation being. developed-for

implementation after outage.

i

,

3) Higher standards being implemented and' accountability being -

i

increased.

'

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4) Management - Union Cooperative Committee being' implemented in

addition to more frequent face to-face meetings _ with management,

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4.2

Present Union Job Description

!

A. ~ Issues

.

-

1) The present combined RES technician (i.e. radiation.

f

- protection / chemistry / environmental) position restricts ability to.

concentrate training and qualification in one area.

f

.

2) Present technician position has minimal entry level requirements'

'

(i.e. high school graduate) which places burden on training and line

.

organization staff.-

,

.

L

B.- Corrective Action

'

,

1) Negotiations =have commenced with union to split RES technicians

~

-job description into two groups. Agreement ~ has been reached on -

the; philosophy of split and the need to raise . entry requirements.

4

Resolution of details on job description,- change to qualification

.

program,' etc. are in progress.

-

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A. Issues

,

1) After four (4) years of apprenticeship program, scope of combined '

technician program too broad for a minimal _ entry level candidate.

2) Continuing training programs are weak 'due;to necessity of -

malatalning quali6 cation in all areas. 'Ihis particularly impairs

ability to focus on operating experience issues.-

3) Supervisory knowledge and interface with program has-been weak.'

4) Supervisory participation in relevant portions of training program

has been minimal.

B. Cor1nsetive Action'

'

1) Upon agreement with union on job description, rewrite qualification

program requirements.-

2) Assess adequacy of Training and RES staffs as part of program

-

redefinition. '

LO

3) First line supervision will attend applicable training following the

1990_ Refuel Outage.

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Risks

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A. Issues .

f

-.

.

,

1) Some technicians and supervisors while perhaps understanding

theoretical aspects of radiological risks, do not implement necessary

'

precautions in the 6 eld.1May be due to. training, past practices,'

lack of reinforcement..

.

2) Some technicians and suwrvisors have reduced radiological

'

-

--

,

-protective measures (or failed to increase protective measuresi

during higher risk evolutions) for convenience without a reasoned -

,

assessment of risk _vs protective measures, ALARA,' personnel

!

safety, etc. -

3) The plant's ALARA program (and radiological work permit review -

- 3

program) is focused on man rem assessment and reduction and not

'

on overall radiological risk (exposure, contamination, etc.)

-

assessment and reduction. '

B.. Corrective Action -

'

1) Training needs to focus (especially in continuing training)

understanding radiological risks especially for infrequent or. " fir

time" evolutions.

'

2) RES personnel have been made aware of issue of reduction of.

H

protective requirements for. convenience (many had not thought of

y

this before). Continued emphasis and review of this issue is

1

4

required. (Third party assessment of certain tasks will be used as

an interim measure until long term corrective actions are in place).

3) ALARA review process will be upgraded to require escalated

management review and approval for radiologically significant tasks

beyond the current colleedve dose requirements. ; Specific review

criteria and radiological assessments will be included to consider--

possible accident or- abnormal scenarios and-to develop appropriate

contingency plans. The escalated management review cnteria will-

consider both the potential severity'of adverse consequences and

decreasing level of experience with the activity.

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4.5

a. ioi.gi i 1 i

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Program, ..d Other Audit Progr.m.

,

A.- Issues

f

1). Some evidence exists that corrective actions resulting from RIR-

critiques are not-being properly implemented (i.e. intent not being

accomplished).

2) RIR and self assessment' programs have a. lot of data concerning

"who, what, when"; however, trending of courses is weak.:

Valuable' data is not being developed and trended. .

3) The majority of assessment programs focus on programmatic-

-issues and results rather than technique and real' time

performance.

-

e

B.

Corrective Action

'

..

.

1) Upgrade causal analysis for RIR and self assessment programs'to

allow trending.

O.

2) Investigate corrective action implementation process to assess 1

effectiveness.-

,

<

3) Assure that self assessment programs devote adequate attention to

~

personnel performance.

.

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_ _ _ , _ _

.

. . - . - -

.

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4.6

Establishanent of Formal Project Tenans.

A. Issues

1) Determination of what events should involve a forrnal

interdisciplinary project team (when RES is one of support) is-

a

undefined. Surely a chemical decon and (now we realize) fuel pool-

cleanup should be in this category, but should an evolution like the:

Na-24 feed test be included?.

B Corrective Action

1) Clarify when interdisciplinary project team should be established for

~

projects.-

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A. Issess

1

1) Some personnel do not fully understand the need e act as an

1

independent monitor, and not become involved in job.

2)- Some personnel do not maintain a questioning attitude and take a

Y

conservative approach when dealing with radiological' practice.'

i

3) Some personnel do not perform self-veri 6 cation before acting.

4)-Some personnel do not understand their own accountability for.

radiological compliance and setting standard. .

B! Corrective Action-

1)- These areas are to be stressed continually during training,

individual and group counseling'and during supervisory' oversight.'

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- co.er.es.r T.chnicians and Supervisor Usage

4..

A. Issoas

1) Large number of contractor technicians-hurts continuity,' continued-

experience factor, strains line and training staffs, etc.-

'

2)-In the past, have used contractors as principal radiation protection

specialists for support of critical plant work permanent experienced-

plant staff used for the development and supervision of important

support programs (e.g. respiratory protection).

'

_

B.' Cornettve Action

1) 1989 added 'seven (7) new technician positions.=

2) 1990 seven (7) additional positions authorized.

3)' Manpower s'tudy to be pedormed for nuclear generation:inisummer

to support future year requests.

!

-

4) 1990 Refuel Outage, chief technicians for all key assignments are-

0.-

permanent NYPA personnel with contractors used as workers.-

4

While short term problems may be experienced overall

improvement is expected due to familiarity'of organization and

normal relationship with supervisors and workers.-

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ML20034B801

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