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Insp Repts 50-352/93-04 & 50-353/93-04 on 930119-22 & 0201-03 & 08-12.Violations Noted.Major Areas Inspected: Circumstances,Evaluations & Corrective Actions Associated W/ Two Radiological Controls Events That Occurred
	ML20034F599
Person / Time
Site:	Limerick
Issue date:	02/26/1993
From:	Eckert L, Nimitz R, Pasciak W; NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	;
Shared Package
ML20034F589	List: ML20034F588; ML20034F599;
References
	50-352-93-04, 50-352-93-4, 50-353-93-04, 50-353-93-4, NUDOCS 9303040038
	Download: ML20034F599 (38)
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U. S. NUCLEAR REGULATORY COMMISSION

REGION I

Report Nos. 50-352/93-04

50-353/93-04

Docket Nos. 50-352

50-353

License Nos. NPR-39

NPR-85

Licensee:

Philadelphia Electric Company

Eggespondence Control Desk

P.O. Box 195

Wayne. PA 19087-0195

Facility Name: Limerick Nuclear Generatine Station. Units I and 2

Inspection At: Limerick. Pennsylvania

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Inspection Conducted: January 19-22. and February 1-3 and 8-12.1993

Inspectors:

RLN'A-

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R. L. Nimitz, CHP, Senior" Radiation Specialist

date

RLM4 &

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L. L. Eckert, Radiation Specialist

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C. K. Battige, Intern

Approved by:

M.

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2-74- D

W. Pasciak, Chief, Facilities Radiation

date

Protection Section

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Areas Insoected: Circumstances, evaluations and corrective actions associated with two.

radiological controls events that occurred on May 31,1992, and January 27,1993. The

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events involved workers handling traversing incore probe (TIP) tubing under, respectively, -

the Unit I and Unit 2 reactor vessels. In addition, planning and preparation for the Unit 2

refueling outage, were reviewed with particular consideration given to identification of failed

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fuel, organization and staffing, external and internal exposure controls, radioactive material-

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controls, and the ALARA program.

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Results: No significant intake of airborne radioactive material by, or external exposure of,

personnel, occurred during the event involving TIP tubing, although the potential for a

significant intake existed in the January 27,1993 event. With regard to the Unit 2 refueling

outage, the inspector concluded that generally effective planning and preparation, in

consideration of the failed fuel, was performed. The inspector also concluded that timely

efforts were taken to up-date radioactive waste shipping data to reflect the potential for

additional radionuclides attributable to the failed fuel. Observations during the outage

identified generally good ALARA efforts. Six apparent violations were identified. The first

apparent violation (Section 7.2.3 of this report) involved failure of the radiological controls

technician monitoring the January 1993 TIP work activity to adequately survey the area and

identify radiological contamination. Such surveys are required by 10 CFR 20.201 to comply

with 10 CFR 20. The second apparent violation (Section 7.2.5), also associated with the

January 1993 TIP activity, involved failure to adequately instruct workers in the presence or

likely presence of high levels of contamination contained within the TIP tubes and the -

precautions and procedures to minimize exposure. Three apparent violations (Sections 7.3.2

and 8.0) involved failure to adhere to radiation protection procedures as required by

Technical Specification 6.11. They involved inadequate preparation for work activities under

the Unit I reactor vessel, inadequate surveys during removal of material from the spent fuel

pool, and inadequate airborne radioactivity sampling during TIP drive work. The remaining

violation was a non-cited violation (Section 8.0) that involvea failure of four workers to sign-

in on the proper radiation work permit, a violation of T.S. 6.11. Lastly, several significant

weaknesses were also identified involving coordination, communication and work control.

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DETAILS

1.0

Individuals Contacted

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1.1

Licensee Personnel

1) 2) J. Doering, Plant Manager.

1) 3) J. Phillabaum, Licensing Engineer

1) 2) G. Murphy, Senior Heakh Physicist

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G. Hunger, Project Manager

T. J. Jackson, Sr. Chemist

R. C. Ragland, ALARA Engineer

T. Mscisz, Assistant Senior Health Physicist

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NRC Personnel

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3) E. Wenzinger, Chief, Division of Reactor Projects Branch 2, RI

1) T. Eastick, NRC Resident Inspector, Limerick Station

2) T. Kenney, NRC Senior Resident

The inspectors also contacted other licensee individuals during the course of

this inspection.

1) Denotes those individuals attending the exit meeting on February 3,1993.

2) Denotes those individuals present at the January 22, and February 8 and 12,

1993, exit meetings.

3) Denotes those individuals present at the January 22, February 3 and

February 8,1993, exit meetings.

2.0

Pumose and Scope of Insnection

This was a combined inspection that included an announced radiological controls

initiative inspection; a special, reactive radiological controls inspection; and an

unannounced radiological controls inspection of outage activities. The following

matters were reviewed:

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The initiative inspection was conducted during the period January 19-22, 1993,

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and focused on review of the licensee's planning and preparation for the Unit

2 refueling outage, including licensee efforts to deal with failed fuel.

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The special, reactive inspection was conducted during the period February I-

8,1993, and included review of events that occurred on January.27,1993, and

May 31,1992. Both events involved workers handling traversing incore

probes (TIPS) tubes. The January 27,1993 event involved workers

disconnecting TIPS and unknowingly introducing very high levels of

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radioactive contamination (measuring up to about 300 millirad /hr removable)

into their work area. The activity resulted in the potential for a significant

intake of radicactive material by the personnel involved. The May 31,1992,

event involved workers testing TIP tubes under the Unit I reactor vessel.

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The inspector review of the outage, conducted during the period

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February 8-12, 1993, included the licensee's implementation of the

radiological controls program for the Unit 2 outage.

During the course of the inspection, the inspector reviewed applicable documentation,

including radiation surveys, independent licensee evaluations, training records and -

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radiation work permits. The inspector also discussed with cognizant personnel the

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circumstances surrounding the TIP events. The inspector observed the approximate

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work area locations using a digital optical tour program (C-Vue) maintained by the

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licensee. The inspector also toured work areas as appropriate and performed direct

observation of on-going work activities.

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3.0

Plannine and Preparation for Unit 2 Outace

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The inspector met with cognizant licensee personnel and reviewed the licensce's

efforts in the area of planning and preparation for the upcoming refueling outage at

Unit 2. The following matters were reviewed:

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planning and preparation in consideration of failed fuel'

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increase in health physics staff, including station's method for ensuring

supervisory control over contracted radiological controls technicians

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special training, including use of mock-ups

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increased supplies, including such items as temporary shielding

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ALARA considerations, including work package review by health physics,

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dose reduction methods, and radwaste reduction

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adequacy of licensee controls and monitoring of contractor work standards

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early involvement of the health physics group and knowledge of work to be

performed.

Evaluation of the licensee's performance in this area was based on discussions with '

personnel, review of documents and independent observations of on-going activities.

The inspector's review indicated that the licensee implemented generally good

planning and preparation for the upcoming outage. The following matters were

identified

The licensee was very sensitive to the need to effectively plan for the Unit 2

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outage in consideration of the identified failed fuel and areas for enhancement

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identified during the last Unit I refueling outage. The licensee's radiological

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controls organization developed a plan to deal with potential Unit 2 failed fuel

concerns. For example, the licensee implemented a special training program

(Radiation Worker Supplement Seminar) for radiation workers. About

800 radiation workers had attended the program. The training program

provided training in areas such communications, emerging issues, and fuel

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failure concerns at Unit 2.

The licensee established and distributed a Limerick Second Refueling Outage

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Manual. The manual included, among other information, the following:

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proper method to change outage work scope

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detailed organization charts

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radiological controls points of contact

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information on reporting quality concerns via the quality concern -

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identification of outage teams and charter for teams (pre-outage, during

outage and post-outage)

This was considered a very good initiative.

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The licensee increased the number of contracted radiological controls

personnel brought on site to support the outage. The technicians were provided

Technical Information Notices designed to inform them of potential

radiological concerns associated with failed fuel. The licensee also provided

dedicated radiation protection supervisors to oversee activities at the refueling

floor and drywell control points.

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The licensee established a work control center to enhance management of

outage activities.

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The licensee developal radiological controls checklists to be used by

supervisors to oversee on-going work activities. Supervisors performed daily -

tours to observe on-going activities and correct concerns as identified using the

checklists.

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The licensee ordered 28 new high efficiency particulate air (HEPA) filtration

units. A number of the units have the capability to be fitted with charcoal

filters for removal of iodine. The licensee also ordered 75 powered air

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purified respirators for personnel use.

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A Shutdown Strategy Task Force was established to plan the Unit 2 shutdown.

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The licensee performed a modified soft shutdown to minimize crud bursts.

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The following matter was noted:

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The inspector selected for review three ALARA Reviews performed for

planned outage work. The three reviews were:

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Control Rod Drive (CRD) and Support Activities

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Main Steam Relief Valves and Modification 6101

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Main Steam Isolation Valve Preventative / Corrective Maintenance.

The inspector's review indicated that although the Unit 2 outage had already

commenced, none of the three reviews selected had been reviewed and

approved by radiological controls and work group supervision for use. Also,

the ALARA review for the CRD work was the Limerick Unit I review from a

previous outage. The inspector's discussion with licensee representatives

indicated that, since the licensee's Unit 2 facility ran at power for about

540 days, and Unit 2 experienced failed fuel, the licensee's ALARA group

delayed approval of the ALARA reviews pending verification of radiation dose

rates. The inspector noted that the reviews were approved when the reactor

was shut down and up-to-date radiation dose rates incorporated into the

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ALARA reviews.

No safety concerns or violations were identified.

4.0

Exposure Controls for Failed Fuel

The inspector reviewed the licensee's internal and external exposure control program

to support outage work activities. In particular, the inspector reviewed the licensee's

enhancements of the program to address potential concerns associated with leaking

fuel elements. The following matters were reviewed:

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exposure estimates for ALARA planning purposes

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acceptability of current dosimetry system for measuring radiation exposure

associated with failed fuel

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instrument calibrations

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hot particle controls

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air sample collection and analysis

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bioassays and assessment of intakes of airborne radioactivity

The inspector's review indicated that the licensee provided good review of potential

radiological concerns associated with failed fuel. The inspector noted that the licensee

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penormed a comprehensive evaluation of poter.dal alpha monitoring concerns. As a

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result of this evaluation, the licensee purchased additional alpha air sample and smear

sample counting systems, revised procedures to provide for improved air sample

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counting capabilities, and reviewed calibration of instruments considering potential

changes in energy spectra of the radiation types to be encountered.

The following matter was noted:

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The licensee calibrated beta radiation survey instruments with a depleted

uranium slab source. Discussions indicated the energy of the source is higher

than the average beta energy in the plant. As a result, the use of the source

would result in slight underestimation of beta dose rates. The licensee's -

radiological controls personnel indicated they were aware of this matter and

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were reviewing the need to purchase new sources.

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The licensee developed draft guidelines for use in evaluating potential intake

by personnel of alpha emitters. The guidelines would be used by personnel in

conjunction with whole body count results to estimate potential intake of alpha

emitters.

The licensee modified surveillance procedures to enhance the survey program

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for alpha e-mitters.

The following matter was brought to the licensee's attention:

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The inspector reviewed the licensee's program for performing skin dose

estimates of personnel contamination. The inspector was initially informed that

the general equation used for initial skin dose estimates was based on dose rate

data for Sr-90. When questioned about the adequacy of the formula and its

applicability for fuel fragment hot particles, the licensee detennined that the

equation was based on Co-60 and that no guidelines were in place for

determination of skin dose attributable to fuel fragments. The inspector's

review indicated that the equation potentially could underestimate the skin dose

by a factor of at least two.

The inspector noted however, that the equation was used for initial evaluation

and that additional, more rigorous, evaluations were performed if the initially

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calculated exposure exceeded 75 millirem. The licensee indicated that

previous calculations would be reviewed to ensure that all appropriate skin

contamination events were reviewed more rigorously if required. The licensee

also initiated action to develop guidelines for determination of skin doses

attributable to fuel fragment hot particles.-

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The inspector's review and discussions with in-field radiological controls

technicians indicated they did not fully understand the ramifications of the

effect of the changes in' the mix of radionuclides on interpretation of

instrument readings. For example, the inspector's review of airborne

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radioactivity data for turbine work on February 7,1993, identified about

107 times the maximum permissible concentration (MPC) for unidentified

alpha emitters and about 80 times MPC for beta emitters. However, a gamma

scan of the same air sample identified only 6 times the maximum permissible

concentration (MPC). The technician who was controlling the work at the

turbine location was not able to inform the inspector as to the significance of

these values and/or which ones were correct and the appropriate values to use

for personnel protection purposes. The inspector noted that personnel in the

work area wore appropriate respiratory protective equipment which provided

more than adequate protection for the identified airborne radioactive

contamination.

The licensee initiated a review of the inspector's observations.

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5.0

Part 61 Analysis

The inspector met with cognizant licensee personnel and reviewed the licensee's

efforts to update Part 61 analyses. The licensee uses the evaluations for purposes of

classifying radioactive waste shipped off site for disposal.

The inspector's review inc'icated that the licensee's radwaste personnel became aware

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of potential changes in the radionuclide abundances via review of periodic sample

analysis results of reactor coolant samples. Discussions indicated appropriate

evaluations and modifications of their radwaste computer program were made in a

timely manner.

No safety concerns or violations were identified

6.0

bl. ARA Efforts

6.1

General

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The inspector reviewed selected aspects of the licensee's ALARA Program.

The principal focus of the review was the observation of on-going work

activities to determine if work was performed in a manner to maintain

personnel radiation exposures as low as reasonably achievable (ALARA). The

review was with respect to general guidance and criteria contained in the

following-

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Regulatory Guide 8.8, Information Relevant to Ensuring that

Occupational Radiation Exposures at Nuclear Power Stations will be As

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Low As Is Reasonably Achievable

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Regulatory Guide 8.10, Operating Philosophy for Maintaining

Occupational Radiation Exposures As low As Is Reasonably

Achievable

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NUREG/CR4254, Occupational Dose Reduction and ALARA at

Nuclear Power Plants; Study on High-Dose Jabs, Iladwaste Handling

and ALARA Incentives.

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Electric Power Research Institute (EPRI) Radiation-Field Control

Manual-1991 Revision

The evaluation of the licensee's performance was based on discussions with

cognizant personnel, independent inspector observations during tours of the

station, observations of on-going work activities, and review of documentation.

The inspector's review of on-going work activities indicated that generally

effective ALARA planning had occurred. The following observations were

made:

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Radiation shielding was installed throughout the drywell to reduce

ambient radiation fields. Informational postings were noted posted at

various locations within the drywell to inform personnel of ALARA

low-dose wait areas and elevated general area radiation dose rates.

Personnel were provided briefings which included radiation dose rate

information.

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The inspector noted that after shutdown of Unit 2 for the outage,

detailed radiation surveys for the drywell showed little if any significant

contamination levels or airborne radioactivity inside the drywell. This

was noteworthy considering the licensee's extensive run of the unit (@

540 days).

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ALARA pre-job review packages were considered to be of generally

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good quality.

The following matters were noted and brought to the licensee's attention:

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During tours of the Unit 2 drywell, the inspector observed. tool boxes

located in elevated radiation fields on various levels of the drywell. In

one instance a worker was observed sorting tools in an elevated

radiation field at the tool box. The licensee moved the tool boxes to

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lower radiation dose rate areas.

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The inspector observed contractor personnel performing non-destructive

testing of piping in the drywell. The inspector observed the individuals

experiencing difficulty attempting to power a light for their work.

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Several of the electrical outlets they tried were net powered. The

workers were searching for power in up to 35 mR/hr radiation fields.

The licensee's radiation protection personnel were aware of the concern

with apparent shortage of powered outlets and were reviewing the

matter.

6.2

Zine Iniection

Industry experience has shown that zine (Zn)in solution in the reactor water

system at BWRs has a positive effect on reducing radiation dose rates on

primary piping (i.e., piping that carries reactor coolant). Some BWRs have

installed systems to inject Zn to reduce radiation fields caused by activation

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product buildup.

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In many plants, Zn is already present, not as an additive, but because of brass

condensers which have leached zine into the coolant system. . If the condenser

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is made of titanium or stainless steel, no zine is available to leach into the

system. Plants with brass condensers and deep bed demineralizers, which are

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more effective at removing ionic impurities than powdered resin

demineralizers, do not show the beneficial effects of Zn since any Zn present

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would be removed by the demineralizers.

During the last outage at Unit 1 (IR04), results of a specific activity survey

performed on the "B" recirculation suction line indicated Co-60 (cobalt-60)

and Co-58 contributed 77.5% of the total isotopic dose. After the first outage

at Unit 2 (2R01), a similar survey showed Co-60 and Co-58 contributed 66%

of the isotopic dose. Any cost beneficial operation which would remove or

lessen the Co coolant concentration and subsequent plate out would reduce

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exposure to plant workers and be consistent with ALARA policies.

In an effort to better remove ionic impurities, to improve plant chemistry,

Limerick Generating Station (LGS) installed deep bed demineralizers for both

units. The new demineralizers became operable in July 1992 at Unit I and

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will become operable at Unit 2 after the current outage (2R02). Since 2n,

which had been present because of the brass condensers, will be removed with

the new demineralizers, LGS installed the General Electric Zinc Injection

Passivation System (GEZIP) to maintain a level of Zn in solution in the reactor

coolant. The system became operational on August 10, 1992, for Unit I and

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February 13,1992, for Unit 2. This activity is governed by LGS Procedure

No. S06.8.B, "Startup of Zinc Injection System," Rev.1, dated April 16,

1992.

The amount of zine injected to obtain the desired level is determined by LGS

Procedure No. CH-830, " Zinc Injection System Zinc Oxide Concentration

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Calculation," Rev. O, dated January 2,1992. The target level for the

feedwater (FW) system is 60 ppm, equal to the amount historically in the FW

system. To prevent plating out of Zn on surfaces exposed to the reactor

coolant, the concentration of Zn is maintained at the level mentioned above

and the zine injection system is shut down when power is below 80%. No

problems have been encountered with the Zn-65 isotope, which has been a

concern at other BWR plants. Zn in the reactor is kept at a concentration of

approximately 1 to 2 ppm.

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Results

No significant reductions in dose rate or coolant activity have been noted with

the GEZIP system in service. However, the licensee identified a number of

factors to explain these results. The current level of Zn (with use of GEZIP)

was essentially the same as previous operation (before deep bed demineralizer

installation). Both units, which are relatively new, have shown very low dose

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rates compared to other BWRs from primary piping, and low levels of

contamination. Indications of potential fuel failure problems on Unit 2, as

discussed elsewhere in this report, began on September 1,1992. Fuel failure

and the resultant release of fission products into the coolant system appeared to

have overshadowed some of the positive exposure reduction effects of the

GEZIP system at Unit 2. The licensee also experience failed fuel at Unit 1.

The inspector noted however, that the licensee's efforts to install the Zn

injection system following the installation of the deep bed demineralizers was

considered a very good ALARA initiative.

No safety concerns or violations were identified.

7.0

Traversing Incore Probe (TIP) Events

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7.1

General Descriotion of the Evgris

On January 27,1993, the licensee experienced a contamination control

problem under the Unit 2 reactor vessel during removal of traversing incore.

probe (TIP) tubes. During the event, workers removing the tubing were

unknowingly exposed to high levels of radioactive contamination. During the -

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review of the event, the inspector became aware of a previous TIP event

which occurred at Unit 1 on May 31,1992. During the earlier event, workers

also v.are exposed unknowingly to high levels of radioactive contamination

while testing TIP tubes under the reactor vessel with a " dummy" TIP tube.

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The inspector reviewed the two events. Evaluation of the licensee's

performance in this area was based on review of documentation, discussion

with cognizant personnel, and observations. The inspector interviewed

workers associated with the January 27,1993, event and discussed the

May 31,1992, event with cognizant radiological controls personnel.

7.2

January 27.1993. Traversine Incore Probe (TIP) Tube Event Description

7.2.1 General

Figure 1 (attached) shows a typical arrangement of the traversing incore

detector system for a boiling water reactor. The detectors (called

probes) are driven by a mechanical drive system locatal in the reactor

building. The drive system drives the probes through a hollow tube

(called TIP tubes), through a drive path selector (called an indexer) into

the reactor core. The drive system consists of five separate drives

(each capable of driving one probe and identified as drives A through

E). The system uses gamma sensitive detectors to provide an axial

indication of neutron flux.

During a refueling outage, a percentage of control rod drive

mechanisms, which enter the reactor vessel from the bottom, are

replaced. In order to remove the drives, the TIP tubes, located under

the reactor vessel, are removed. Prior to their removal, the detectors

are retracted into special shields located in the TIP Room (also located

in the reactor building).

Because the tubes are lined up in rows, the tubes are typically removed

by removing the outer rows first followed by the inner rows. The rows

are lettered A through G. Figure 1 shows the location of the TIP tubes

and the area where the workers were working.

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7.2.2 Description of Event

The task of removing the TIP tubes was assigned to a Nuclear .

Maintenance Division (NMD) Reactor Services Section work group on

January 26,1993. The actual planning and preparation for the work

activity was conducted during the period January 18-22, 1993.- At that

time, the Job Foreman met with cognizant radiological engineering _

personnel and discussed the work activity and ALARA review. Matters

that were discussed included removal path of the tubes, storage

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locations, and use of " dose bags" to minimize potential contamination.

The " dose bags" are small plastic bags typically used to contain

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personnel dosimetry and preclude its contamination when working in

contaminated environments. The bags were to be placed over the ends

of the TIP tubes to prevent release of radioactive contamination from

the tubes. The bags were being used in lieu of plugs or caps specified

in procedures due to the unavailability of a sufficient quantity of plugs

or caps.

Note: The inspector determined that the radiological engineering

personnel did not expect any.significant' contamination associated

with the removal of the TIP tubes. The inspector was informed

that typical levels previously encountered were on the order of

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50,000 disintegrations per minute (dpm) per 100 cm . The

inspector verified this by review of all post outage reports for

Units 1 and 2. It was noted during this review, however, that a

significant contamination event involving improper testing of -

TIP tubes occurred on May 31,1992, during the Unit 1 fourth

refueling outage. (See Section 7.3 of this report.)

The work crew that was to remove the TIP tubes normally worked

from 10:00 p.m. to 8:00 a.m. the following morning. At about

10:00 p.m. on January 26,1993, the Job Foreman met with the Job

Leader responsible for directing the work crew. The Job Foreman

provided a copy of the ALARA review for the task to the Job I2ader

and discussed the performance of the task. Prior to performance of the

task, the Job Leader walked down appropriate sections of the clearance

request and system tagout (Clearance No. 92007667). The Job leader

also provided a pre-job briefing to the work crew. The crew had been

selected based on their level of experience with the system.

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Note: Inspector discussions with individual work crew members

indicated the workers either had extensive experience working

with the TIP system and/or had attended training on the TIP

system at the licensee's training center.

A radiation work permit (RWP) (No. 07027, Revision 0,

Remove / Install and Test Tip Tubes) was issued for the work activity on

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January 22,1993. Among other controls, the permit required a survey

on breach of the system. Personnel signed in on the RWP compliance

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sheet indicating they had read and understood the permit. The workers

also received an ALARA briefing from the radiation protection drywell

control point leader. The complete ALARA review (Removal of TIP

Tubing and TIP tube Supports, dated January 22,1993) for the task

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was covered during the briefing. During the briefing, workers were

informed that the interiors of the TIP tubes were contaminated.

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Subsequent to the briefing, workers signed into the work area using

" live time" computer sign-in. The workers wore one set of protective

clothing and a faceshield.

The actual removal of the TIP tubes involved two separate entries

under the reactor vessel by work crews consisting of 5 individuals.

During the entries, four individuals entered the area under the reactor

vessel to remove the tubes while the Job Ieader remained outside the

control rod drive chute to remove and store the TIP tubes.

The first entry was made at about 1:00 a.m. on January 27,1993 and

lasted about 1.5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br /> (about 1:00 a.m. to 2:30 a.m.) A radiation

protection technician accompanied the four workers under the reactor

vessel during the entry and made general area radiation measurements

and smear checked both the inside and outside of the tubes. A cotton

swab was used to smear check inside the tubes.

Note: The inspector's discussions indicated that only two tubes

were checked inside for smearable contamination. These tubes

were apparently in the A and G row of tubes.

Note: The radiadon protection technician who accompanied the

work crew had no previous experience in oversight of removal

of TIP tubes. In addition, the review of the individual's

qualification card indicated he had not been authorized (based on

lack of a Radiation Protection Supervisor signature) to perform

work independently. The radiation protection drywell control

point leader did not know that this individual had no previous

experience in removal of TIP tubing however, he felt that he

was an experienced individual.

The survey (Reference Survey No. 93-02527) made during the work

indicated general area radiation levels of about 8-120 millirem /hr

(depending on proximity to bottom head drain line) and contamination

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levels of less than 1000 dpm/100 cm on the exterior of the TIP tubing.

However, the interior of the TIP tubing measured up to 1600

millirad /hr (beta dose rate) on contact with the opening of a tube and

up to 4 millirad /hr per cotton swab removable surface contamination.

The workers were not informed of these latter readings. The radiation

protection drywell control point leader was informed of these readings.

The readings were not considered of concern. An air sample collected

during the entry indicated 18% maximum permissible concentration

(MPC) when field counted at 3:00 a.m. on January 27,1993.

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The workers completed removal of 4 of 7 rows of tubes (A and B, F

and G), and exited the area about 2:30 a.m. The workers used whole

body friskers at the Unit I drywell because the Unit 2 whole body

friskers were apparently out of order. The workers' frisk indicated no

contamination was present.

The second work crew entered the area about 4:00 a.m. on January 27,

1993, and worked until about 5:30 a.m. This work c'rew consisted of

the same work crew as the previous entry with the exception that one

worker was replaced by a different worker. The new worker received

a pre-job briefing from the Job Leader. The workers were not

accompanied by a radiation protection technician and no additional:

radiation surveys or contamination checks were performed as the

workers removed the remaining rows of TIP tubes (Rows C, D and E).

Unknown to the workers, the tube rows associated with TIP drive E

were highly contaminated, with contact beta radiation readings on the

ends of the tubes measuring up to 24,000 millirad /hr. Removable

contamination inside the same tubes measured up to 1000 millirad /hr on

~

a small cotton swab.

Note: These values were based on measurements made on

January 30,1993, and have not been decay-corrected to -

January 27,1993. Because of the short half-lives of

molybdenum-99 and technetium-99m, the initial values, on

January 27,1993, would have been higher. Figures 3 and 4

(attached) provide the results of the licensee's contamination and

radiation measurements of each TIP tube.

An air sample was collected during the second entry. The sample,-

,

which ran from 5:15 a.m. until about 5:50 a.m., was analyzed and

indicated 22% MPC.

When the work crew exited the drywell and removed their protective

clothing, they attempted to use the whole body friskers at the Unit 2

drywell, but found them to be out of service. The work crew exited

Unit 2 and used the whole body frisker at the Unit I drywell control

point area. Of the 5 individuals involved in the work activity,4 were

found to be contaminated. Three of the workers exhibited nasal and

'

skin contamination.' Maximum nasal contamination. identified on any

one individual was 3000 counts per minute (cpm) per cotton swab. The

maximum skin contamination detected was about 2000 cpm using a

2

15 cm end window probe. One of the four workers who was

contaminated was believed to have become contaminated after he exited

i

.

16

the work area. The inspector noted that one of the five workers had

put on portions of street clothing (pants) prior to frisking and had

carried his other street clothes to Unit 2. This worker's clothing was

found to be contaminated.

Subsequent contamination surveys taken in the area at 6:45 a.m. on

,

January 27,1993, identified contamination levels on the grating under

2

the reactor vessel of up to 320 millirad /hr per 100 cm . A

contamination survey made at 7:00 a.m. on the same day identified

contamination levels on the grating in the area under the reactor vessel

2

ranging from 8 to 240 millirad /hr per 100 cm removable

contamination. The licensee believes a fan may have been started

which dispersed the contamination. A survey taken outside the area of

the control rod drive (CRD) chute and general areas of the 238'

elevation of the drywell identified contamination levels ranging from

2

10,000 - 300,000 dpm/100 cm . Prior to the event, these same areas

2

exhibited contamination levels less than 5,000 dpm/100 cm . The

inspector noted that portions of these areas were accessible to personnel

in street clothes who wore protective shoecovers.

Figure 2 (attached) shows the contamination levels generated following

the removal of the TIP tubes. Figures 3 and 4 (also attached) show the

levels of contamination of the TIP tubes. Figure 3 shows the data

arranged by TIP tube row. Figure 4 shows the data arranged by TIP

drive box. (Note the elevated contamination levels associated with

drive box E.)

7.2.3 January 27.1993 Event - Exoosure Controls

The inspector reviewed the external and internal exposure controls

provided for the work activity. The review was with respect to criteria

,

contained in 10 CFR Part 20, Standards for Protection Against

Radiation and applicable provisions of the licensee's Technical

Specifications. The review was also with respect to criteria contained

in the following procedures:

.

-

A-C-107, Revision 0, Radiation Work Permit and Radiological

Controlled Area Access Requirements

.

-

HP 310, Revision 25, Radiation Work Permits

-

HP-216, Revision 3, Performance of Breach Surveys

-

HP-234, Revision 2, ALARA Job Reviews

-

HP-211, Revision 6, Contamination Survey Techniques

-

HP-317, Revision 2, TIP Drive Unit Access

.

17

-

M-059-001, Revision 4, TIP Tube and Support Steel Removal and

Installation

1

The evaluation of the licensee's performance in this area was based on

i

discussions with cognizant personnel and review of procedures.

j

The inspector's discussions with personnel revealed that the work activity

involving the removal of TIP tubing had been performed previously at Unit 1

'

during the past 4 refueling outages and the past refueling outage at Unit 2.

During the previous removals, similar protective clothing (i.e., a single set of

protective clothing and a faceshield) was worn. Also, respiratory protective

,

equipment was not used during the previous removal efforts. The licensee's

radiological controls personnel did specify faceshields to be worn to preclude

inadvertent facial contamination. The inspector's discussions with the

licensee's personnel indicated contamination levels in the area under the vessel

were relatively low and the expected contamination level contained within the

2

TIP tubes was about 50,000 dpm/100 cm . No airborne radioactivity was

encountered during the previous removals.

The inspector noted that during the initial removal efforts on January 27,

1993, between about 1:00 a.m and 2:30 a.m. the licensee's radiation

i

protection technician performed contamination monitoring and noted

contamination levels of up to 8 millirad /hr per cotton swab smearable inside

,

the ends of the tubes and up to 1.6 rad /hr (beta) at the ends of the TIP tubes.

However, this individual was unaware of the expectation that the tubes

typically exhibited substantially lower contamination levels (i.e.,

2

50,000 dpm/100 cm ). The survey information was relayed to the radiation

protection drywell control point leader, but the information was not considered

of concern. As a result of the belief that the readings did not pose any

concern, the radiation protection technician decided that there was no need to

perform any further surveys during the second portion of the tube removal

I

activity.

During the second portion of the removal effort on January 27,1993, from

about 4:00 a.m. to 5:30 a.m., the workers unknowingly disconnected TIP

j

tubing that exhibited high levels of loose surface contamination. Subsequent

'

measurements made by the licensee indicated removable contamination levels,

contained within the tubing, ranged up to 24,000 millirad /hr per cotton swab.

(see Figures 3 and 4 to this report.) Although these levels were contained

within the tubing, upon disconnection at least one end of the tubing was

exposed prior to its bagging. This provided an opportunity for the

contamination to exit the tubing. The inspector noted that contamination levels

2

ranging up to 320 millirad /hr per 100 cm were identified in the work

location.

.

>

9

18

The inspector noted that 10 CFR 20.201(b) specifies that licensees shall make

surveys as (1) may be necessary to comply with the regulations in this part,

and (2) are reasonable under the circumstances to evaluate the radiation

hazards that may be present. 10 CFR 20.201 (a) defines a survey as an

evaluation of the radiation hazards incident to the production, use, release,

disposal or presence of radioactive materials or other sources of radiation

under a specific set of conditions. When appropriate, such evaluation includes

a physical survey of the location of material and equipment, and measurements

oflevels of radiation or concentrations of radioactive material present.

The inspector noted that the initial measurements made by the radiation

protection technician monitoring the removal of the TIP tubes identified

contamination levels considerably above those previously encountered during

TIP removal operations. However, neither additional measurements were

made to evaluate the extent of the radiation hazard present during subsequent

removal of TIP tubes,' nor was an adequate evaluation of the hazard presented

by the elevated contamination levels made. As a result, very high levels of

radioactive contamination were introduced into the work area of 4 workers,

and 3 of the workers sustained personnel contamination. The licensee's

evaluation indicated no significant intake of radioactive material had occurred.

The inspector noted, however, that the lack of a potentially significant intake

,

of airborne radioactivity was fortuitous and not the result of protective actions

taken by the licensee. For example, as discussed above, additional sampling

was not performed to evaluate the radiological hazard present, contamination

j

2

levels ranged up to 320 millirad /hr per 100 cm , and air currents apparently

dispersed the contamination within the undervessel area resulting in levels

2

ranging from about 8 to 240 milliradihr per 100 cm . In addition, the workers -

were working in close quarters in a hunched over fashion, making intakes of

material falling out of open tubing even more possible. The inspector noted

j

i

that although no significant intakes of airborne radioactivity occurred, the

inspector concluded that the failure to make appropriate measurements and

adequately evaluate the hazards of the presence of high levels of loose

contamination contained within TIP tubing on January 27,1993 was an

-l

apparent violation of 10 CFR 20.201(b).'(50-353/93-04-01)

The following additional matters were noted:

1

-

The radiation protection technician assigned to control the radiological

.I

work activities under the reactor vessel had not previously provided

such oversight for TIP tube removal.

J

l

-I

.-

I

.

19

The job planning within the radiation protection group was poor in that

-

it did not provide specific guidance and criteria to the radiological

controls technician controlling the job, and in particular it did not

provide specifics as to whether each tube coupling joint needed to be

surveyed when breached or what actions to take following survey

results.

The ALARA planning for the TIP removal, as discussed above was

-

based on an expected internal contamination level of the TIPS of about

2

50,000 dpm/100 cm . This was not communicated to the radiological

controls technician providing radiological oversight of the TIP removal.

Consequently, the technician was unaware of the significance of the

increased contamination levels.

-

The licensee had experienced an event involving the TIP tubes during

the fourth refueling outage at Unit 1. The event, which occurred on

May 31,1992, and is further discussed in Section 7.3 of this report,

'

involved workers testing TIP tubes prior to installation. The work

activity, which also was performed under the reactor vessel, was not

adequately evaluated by radiological controls personnel in order to

establish appropriate radiological controls for future TIP tubing work.

-

The licensee's corporate group reviewed the event and concluded that

corrective actions for previous events had not been effective in

precluding this occurrence. In addition, the inspector's review of the

May 31, _1992, TIP event indicated that, not withstanding the difference

in work activity that was performed (i.e, removing TIP tubes versus

testing of TIP tubes prior to installation), the corrective actions for the

May 31,1992, event were not effective in precluding occurrence of

-

the January 27,1993, event. Specifically, the method of contamination

control was not effective.

The inspector concluded, based on the above information, that the licensee's

!

radiological controls for the removal of the TIP tubes relied primarily on

previous experience with this work activity and that the program did not

effectively control the work activity when elevated levels of radioactive

l

contamination, substantially in excess of those contamination levels previously -

identified, were encountered. In addition, the high levels of contamination

encountered by personnel were attributed to weaknesses in the licensee's

corrective actions for a previous undervessel contamination event that occurred

in_ May 1992. These observations were considered reflective of program

weaknesses in the area of planning for and oversight of work.

,

m

.

20

.

7.2.4 E.x.J8mtre Assessment

The inspector reviewed the internal and extetnal exposure assessments

made by the licensee. The inspector reviewed this ' matter with respect

to the criteria provided in 10 CFR Part 20.

The evaluation of the licensee's performance in this area was based on

,

review of exposure results and discussion with cognizant personnel.

The inspector's review of the licensee's results indicated that personnel

did not sustain any significant intake of airborne radioactive material..

-

The initial indications of intake of airborne radioactive material were

'

attributed to personnel skin contamination. Tbc inspector noted that the

licensee needed to re-adjust the whole body counter energy

discriminators in order to readily detect the molybdenum. The skin

exposure of personnel was estimated to be negligible.

7.2.5 Iri ning and Oualifications

d

The inspector reviewed the training and qualifications of personnel

involved in the January 27,1993, undervessel contamination event.

The inspector reviewed this matter with respect to criteria contained in

10 CFR 19 and applicable licensee procedures.

The evaluation of the licensee's performance in this area was based on -

discussions with personnel and review of training records. The

inspector's review indicated the following:

The Job Foreman met with radiological engineering personnel

-

,

about one week prior to the performance of the task. and

,

discussed the task.

The Job Foreman and Job Izader discussed the work activity

-

prior to performance of the task.

The Job leader met with the work crew assigned to remove the

-

TIP tubes. The Job Leader discussed how the task was to be

performed and where the TIP tubes were to be stored.

+

The radiation protection drywell control point leader briefed the

-

workers on the expected radiological conditions. The control

'

point leader read and discussed the ALARA Pre-Job Evaluation.

(RWP LG-2-93-07027, WO No. R0458361).

,

--

4

_

-

..

,.

.

,

w

'

a ,

.9-

.

j

!

y:

21

_

j

The individuals who removed the TIP tubing had either previous -

-

i

experience removing the tubing or had attended special training

on this task at the licensee's training center.

l

f

!

-

The workers who performed the task were appropriately.

qualified in accordance with General Employee Training and

y

Radiation Worker requirements.

j

i

'

The inspector reviewed the training and qualifications of the radiation

protection technician who provided radiological oversight of the initial

!

removal of the TIP tubing on January 27,1993. The individual met -

1

the experience requirements of Technical Specifications.' The inspector

l

noted, however, that this was the first time this individual provided

q

ra<liological oversight for removal of TIP tubing. The inspector's.

1

review of the individual's training record indicated he had completed -

j

his on-the-job training requirements. The'se requirements included '

performance of breach surveys. The inspector noted, however, that

,

Step 4 of the technician's training record had not been signed off by a -

Health Physics Supervisor. ' The signature acknowledges that the L ~

,

f

vendor technician has satisfactorily completed the vendor. qualification

sheet and can perform the above tasks without supervision.~ The -

j

-

inspector noted that the licensee's training program procedure (TQ-C-7,-

1

Revision 1,Section 7) specifies that line supervision verifies by

]

signature /date that all required entries have been completed. The

inspector indicated that failure to complete the specified' sign-offs prior'

to allowing the technician to ' perform independently was considered a

1

weakness.

'~

-

More significantly, this individual was unaware of the expectation that

the tubes typically exhibited substantially lower contamination levels .

2

(i.e.,50,000 dpm/100 cm than actually found). The actual ' survey

i

information was relayed to the radiation protection drywell control L

point leader, but the information was not considered of concern. ' As a

>

result of the belief that the readings did not pose any concern, the

j

radiation protection technician decided that there was no need to -

1

perform any further surveys during the second portion of the tube

!

removal activity.

,

The inspector's review of the information provided to the workers .

+

under the reactor vessel indicated that on January 27,1993, between

about 1:00 a.m and 2:30 'a.m. (during the first entry) the licensee's -

!

radiation protection technician performed contamination monitoring and

'

noted contamination levels of up to 8 millirad /hr per cotton swab

.

I

smearable inside the ends of the tubes and up to 1.6 rad /hr (beta) at the-

,{

a

'

.

,

.

h

4

22

'

,

ends of the TIP tubes. The radiation protection technician did not

inform the workers of the levels of contamination present. The

inspector's discussions with the workers indicated that the workers were

.

informed that th?. conditions under the reactor vessel were relatively

clean. The waaers were informed to place " dose bags" over the ends

of the tubing to prevent escape of contamination. Based on the

2

contamination levels encountered (up to 320 millirad /hr per 100 cm

removable) the inspector concluded that the method used to install the

dose bags, or the dose bags themselves, were not adequate.

The inspector noted that 10 CFR 19.12 requires that the licensee

c

inform workers of the storage, transfer, or use of radioactive materials

and in precautions or procedures to minimize exposure. The inspector

noted that, on January 27,1993, the licensee did not adequately inform

'

workers as to the presence of high levels of radioactive contamination

or of means to minimize their exposure to such contamination.

Specifically, at about 2:00 a.m., workers were not informed of the

presence of high levels of radioactive contamination contained within

traversing incore detector tubes when such contamination was detected

by a radiation protection technician's measurement. This is an apparent

violation of 10 CFR 19.12 (50-353/93-04-02).

7.2.6 Licensee Assessment

The inspectors' review indicated that the licensee assembled a multi-

disciplinary team to review the event. The team leader reported

directly to the licensee's Vice President- Limerick Station. This was

considered an excellent licensee initiative to understand the root causes

of the event. The team used state-of-the-art investigative techniques.

I

The inspector noted that the team identified a number of apparent root

causes. Some of the more significant ones are as follows:

There was an insufficient understanding of the likelihood of

-

contamination.

-

There were less than adequate surveys.

-

There was less than adequate communication of survey

infonnation.

.

.m

-.

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.-.

1

23

,

7.3

May 31.1992. Undervessel Contamination Event (Unit 1)

,

s

7.3.1 Description of Event

i.

On May 31,1992, two drywell entries were made during the second

J

shift to conduct TIP work. The first entry was made at the'beginning

of the second shift (@ 2:00 p.m.). The Nuclear Maintenance

Department (NMD) held a pre-job brief concernir n TIP installation and

testing and mechanical stop installation. Radiation protection personnel

were not apprised of this meeting or included in it. However, both

tasks were discussed at the drywell radiation protection control point

and a limited discussion with radiation protection personnel occurred

there.

,

Note: At this meeting, radiation protection personnel were not

apprised that the TIP testing would be performed under the -

reactor vessel versus at the TIP indexer, which is located under

..

the floor grating on the 253' elevation of the drywell outside the

biological shield. The NMD work crew did not inform the

radiation protection control point leader that they intended to test

TIP tubing from the subpile room bridge.

At that time, radiation protection personnel waived the Radiation Work

Permit (RWP) restriction of no subpile room entry to allow movement

of a ladder (only). Workers entered the area under the Unit I reactor

vessel and performed testing of TIP tubes via insertion of a dummy TIP

probe into the tubes. The probe was used to check for any apparent

restrictions in the tubes. The first entry under the vessel occurred

,

between about 3:26 p.m.' and 6:35 p.m. The workers worked on

mechanical s'. ops for the undervessel platform and performed some TIP

testing by ranning the dummy TIP detector in and out of the TIP tubes.

The workers exited the area for lunch with no concerns noted. An air

sample collected during the period 2:30 a.m. to 4:40 p.m. that day

indicated low airborne radioactivity (< .1 times the applicable

10 CFR 20, Appendix B concentration values).

Note: Because no radiation protection personnel had been

.

informed of the planned work activity, the. workers did not have

the benefit of grab sampling for airborne radioactivity or

periodic measurement of radiation and contamination levels in

their work area.

i

,

4

s

.

~

24

.

Note: When the workers exited for lunch, the dummy TIP cable

and detector were brought out of the under vessel area and

placed on a frisking table at the drywell control point.

Radiation protection personnel were not informed of this action.

No radiation protection personnel were at the control point.

After exiting the drywell, two workers alarmed personnel contamination

monitor (PCM)-1B at the personnel air lock, prcc~xled to a PCM on

Unit 2 253' elevation, and cleared this monitor.

During the second entry between about 8:46 p.m. and 10:53 p.m., the

workers did not use a dummy TIP probe. An airborne radioactivity

sample, collected during the period 4:45 p.m. to 11:30 p.m. that day,

indicated .57 times the applicable 10 CFR 20, Appendix B

concentration values.

,

During this second entry, the drywell radiation protection control point

leader found the dummy TIP cable on the frisking table. Further

investigation by radiation protection personnel found that smear results

2

on the table were 60 mrad /hr per 100 cm (typically < 1,000 dpm/

2

100 cm ) and the cable measured 16-40 mrad /hr per 100 cm ,

,

Frisking around the normally clean areas near the frisking table showed

2

300 cpm, as measured with a direct reading GM detector (15 cm ),

Radiation protection personnel questioned NMD personnel concerning

the dummy TIP cable and received no definitive answers. After the

NMD workers exited the drywell, radiological controls personnel

pursued this matter again; the NMD workers apparently continued to

deny any knowledge conceming the dummy TIP cable.

After exiting the drywell the second time, the worker who had used the

dummy TIP cable alarmed the personnel air lock PCM-1B and the Unit

2 PCM. Radiation protection surveys found contamination on the

worker's face, neck, and knees of about 400 to 900 cpm per 15 cnf.

The worker was decontaminated and informed radiation protection

personnel that the cable was a dummy TIP cable and that his work

crew had been using it to test TIP tubing for obstructions.

The inspector noted that subsequent contamination checks under the

reactor vessel identified generally low contamination levels (generally

2

less than 20,000 dpm/100 cm ). One smear indicated 80 millitad/hr,

2

per 100 cm , but was not considered to be in the work location. This

event was documented by the licensee in Radiological Occurrence

Report (ROR)92-025. The ROR was approved on September 11,

1992.

.

25

7.3.2 May 31.1992 Event - Exposure Controls

The inspector reviewed the exposure controls implemented for under-

vessel work. The inspector noted that a radiation work permit was

issued for the work task (RWP No. 1-92-07027, Remove, Install, and

Test TIP Tubes).

The inspector noted that the maintenance work request for this activity

(R0050221), Remove TIP Tubing and Support Steel as Required,

contained as ACTIVITY 6, the task to examine TIP tubes for kinks or

restrictions. This activity, according to discussions with radiation

protection personnel, was planned and had previously been performed

at the TIP tube indexer locatei below the grating on the 253' elevation

'

of the drywell. However, the work crew decided that the activity was

to be performed under the reactor vessel. Radiation protection -

personnel were not informed of this change in location.

The inspector noted that radiation protection procedure A-C-107,

Radiation Work Permit Program and Radiological Controlled Area

Access Requirements, Revision 0, specifies in Section 7.7.5, that health

physics shall brief workers prior to RWP entry on radiological

conditions commensurate with the work to be performed and the areas

a

being accessed. The inspector noted that such instruction was not given.

because workers failed to inform the radiation protection personnel

(health physics) of the activity they were to perform and the areas to be

accessed.

,

The inspector further noted that radiation protection procedure A-C-107

specifies in Section 7.1.2 that all personnel entering the radiological

-

'

controlled area shall employ proper radiological work practices as

presented in Exhibit A-C-107.5 of procedure A-C-107. Exhibit A-C-

107.5 provided examples of proper radiological work practices, which '

included the need to prepare and plan for all radiological controlled

area work sufficiently in advance to allow proper health physics

review. The inspector noted that the maintenance personnel did not

adequately prepare for the undervessel work in advance to allow health

,

physics review in that 1) radiation protection personnel were not

included in a pre-job briefing to discuss the testing of the TIP tubes .

under the reactor vessel and 2) workers entering to perform actual TIP

testing did not inform radiation protection personnel at the drywell

control point that they would be performing TIP tube testing under the

reactor vessel.

4

.

26

The failure of the workers to properly prepare for the work activity and

'

allow for proper health physics review was considered an apparent

violation of Technical Specification 6.11, which requires adherence to

'

radiation protection procedures. (50-352/93-04-03)

7.3.3 Exposure Assessment

The inspector reviewed the exposure assessment for personnel involved -

in the May 31,1992, undervessel TIP event at Unit 1. The inspector's

review indicated one individual sustained a limited intake of airborne

radioactive material. Maximum exposure sustained by any one

individual was 28 MPC-hrs. This was well below the allowable intake

permitted by 10 CFR 20 (520 MPC-hrs).

7.3.4 Licensee Review

Foilowing the May 31,1992, event, the licensee's corporate group

reviewed the event. The licensee's reviews indicated the following:

-

There was poor communication between the work crew and

radiation protection personnel concerning work scope

-

The TIP Procedure was less than adequate as to the proper use

of t!c dummy TIP and radiological precautions

-

The pre-job briefing on radiological conditions was inadequate

in that radiation protection personnel were not present.

-

The knowledge level of the maintenance crew of the radiological

hazards associated with working on the TIP system was less

than adequate

-

The corrective actions for a previous event were less than

adequate.

-

There was a difference in the degree of radiation protection

coverage of NMD work between Peach Bottom and Limerick

i

Stations.

7.3.5 Previous Examples of Violations Associated with Inadeauate

Communications

1

The inspector noted that the licensee became aware of the May 31,

1992, TIP event when workers were identified as contaminated

following work under the vessel. The inspector noted that, in essence,

the licensee's corporate review team identified the weaknesses in

adequate planning and preparation (attributable to weaknesses in

communication between radiation pretection and maintenance

.

4

.

27

personnel), characterized above by the inspector as an apparent

- violation. This violation was similar in cause to a violation issued in

March 1992 (Reference NRC Combined Inspection Report No.

50-352/92-13; 50-353/92-13). The corrective actions for that previous

violation could reasonably have been expected to have prevented the -

,

May 31,1992, apparent violation.

.

8.0

Eadiological Controls

The inspector reviewed routine radiological controls implemented for the refueling

outage at Unit 2. The inspector also reviewed routine radiological controls activities

during tours of Unit 1. The inspector reviewed the following elements of the

license's radiological controls program:

,

-

training and qualification of radiological controls contractor personnel

supporting outage work activities

-

performance and adequacy of radiological surveys to support pre-planning of

work and on-going work

-

use of appropriately calibrated instrumentation to measure radiation and

contamination

-

personnel adherence to radiation protection procedures, radiation work permits

and good radiological control practices

!

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posting, barricading and access control as appropriate, to Radiation, High

Radiation, and Airborne Radioactivity Areas

-

use of dosimetry devices

.

.i

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airborne radioactivity sampling and controls, including installation and use of

engineering controls to minimize airborne radioactivity

use of respiratory protection devices.

-

The evaluation of the licensee's performance in this area was based on discussions

with cognizant personnel, review of on-going work activities and review of various

documents.

The inspector reviewed, among other activities, the following:

-

fuel inspection and sipping

-

control rod drive removal and replacement

-

main steam isolation and pressure relief valve work

-

removal of the E- traversing incore detector probe and cable from the E-drive

The inspector identified the following apparent violations:

Non-Cited Apparent Violation (Failure to follow RWP procedure)

.

- .

-

- -

-

- -

i

e

28

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During tours of the Unit I and 2 Refueling Floors on January 19,1993, the

j

inspector noted that the licensee recently initiated radiation work permit (RWP) .

live time computer tracking of workers on the refueling floor. Using this

!

sign-in method, workers sign a form (A-C-107.3A) indicating they have read

and understood their radiation work permit. The workers may then sign in

i

and out of the work area via computer after the radiological controls personnel

,

have authorized live time sign in and out.

At about 1:30 p.m. on January 19, 1993, the inspector observed four

individuals standing on the Unit 2 refueling bridge performing underwater

clean-up activities from the bridge. The workers were suited up in full

u

protective clothing. The following was noted:

,

-

Worker A, performing work on the refueling bridge, was signed in on

form A-C-0107.3 of Radiation Work Permit No. 7070, Operate, Survey

and Inspect Bridge, Revision 1, dated January 19, 1993, but had

actually signed in on (via live time) RWP No. 7051., revision 1,

Support Disassembly, dated January 18,1993.

-

Worker B, also performing work on the refueling bridge, had signed in

on form A-C-107.3 of RWP 7051, Revision 1, but did not sign in at all

(for the work period) on the live time computer prior to working on the

refueling bridge.

The inspector further noted that Unit 2 Technical Specification 6.11 requires

that radiation protection procedures be adhered to. Radiation protection

procedure A-C-107, Radiation Work Permit Program and Radiological

'

Controlled Area Access Requirements, Revision 0, states in Section 7.7 that

personnel are to log into the appropriate dose tracking system and sign the

RWP compliance sheet. The inspector noted that failure to sign in on the

correct RWP compliance sheet and sign in on the dose tracking system was an

apparent violation of TS 6.11. The inspector's discussions with personnel and

observations indicated the following:

<

-

The personnel were immediately removed from the area and required to

sign in on the proper RWP.

-

The workers had been directly obstved by radiological controls

personnel.

-

The workers had been briefed on the proper RWP requirements.

-

The licensee informed all appropriate work crews of this matter.

In light of the above corrective actions and minor health and safety

significance, this matter was considered a non-cited inspector-identified

,

violation.

.

,

29

The inspector's review noted that the two other individuals on the refueling

bridge at the time were not properly signed in on their radiation work permits.

The individuals had signed in (via live time) on Revision 1 of RWP No. 7070,

but they had actually signed Revision 0 of Form A-C-107.3. A radiation

protection technician had apparently authorized the workers to work on

revision 1 of RWP No. 7070 without noticing that they had not signed a sheet

indicating that they had read and understood Revision 1 of RWP No. 7070.

The workers had been properly briefed and, as discussed above, the

individuals were removed from the area and signed the proper documentation.

l

Despite this, the inspector concluded that the workers did not exhibit attention

to detail regarding conformance with radiation protection procedure

requirements.

The inspector's review of this matter indicated that the licensee's radiation

work permit procedures provided little guidance for actions to be taken (either

by workers or radiation protection personnel) following revision of an RWP.

The licensee immediately initiated action to change the procedure and include

the guidance.

The inspector also noted that the licensee's on-site QA group had recently

completed an audit of radiological controls activities. The inspector's review

of the draft audit findings indicated a number of weaknesses had been

identified in the radiation protection area. The inspector indicated to licensee

management that, in light of start of the Unit 2 outage, these weaknesses

should be reviewed for possible enhancements in a timely manner.

Apparent Violation (Failure to Follow RWP Procedure)

-

During observation of fuel inspection activities in the Unit I spent fuel pool at

.

2:30 p.m. on February 2,1993, the inspector observed two contractor workers

removing long handled fuel and fuel channel handling tools from the water.

About 15-20 feet of the fuel handling tool was raised out of the water and

wiped down by hand as an irradiated fuel element was raised and lowered in

the fuel inspection station. About 10 feet of the fuel channel tool was raised

from the pool as the channel was placed back over the fuel following the

inspection. The inspector noted that the radiation work permit controlling the

activity (RWP No. 2-93-07063, Revision 3, Perform Fuel Inspections) stated

in the special instructions and remarks section of the RWP that Health Physics

shall survey all items being removed from water.

The inspector's discussion with the lead radiation protection technician

,

controlling the activity indicated that the tools were surveyed, but that the

technician who had been performing the surveys was called to another location

to survey another item being removed from the pool.

. - -

- .

30

The inspector noted that the licensee's access control and radiation work

permit procedure (A-C-107, Radiation Work Permit Program and Radiological

Controlled Area Access Requirements, Revision 0) states in Section 5.0 that

all workers are to comply with the requirements of the appropriate radiation

,

work permit. The inspector noted that the two contractors did not comply

with the requirements of the radiation work permit in that health physics did

not survey the tools as they were being removed from the water. This is an

apparent violation of Technical Specification 6.11, which requires adherence to

radiation protection procedures. (50-352/93-04-03)

The radiation protection technician informed the contractor workers regarding

'

the need to survey material being removed from the water.

Apparent Violation (Failure to Follow Radiation Protection Procedures)

-

On February 11,1993, during the period 7:00 a.m. to about 10:00 a.m., the

inspector observed the set-up and preparation for the removal of the E-TIP

detector drive cable and probe. The inspector also reviewed video tapes of the

activity. The inspector noted that during the time period, workers periodically

stuck their heads and upper body into the TIP drive box. Figure 5 (attached)

shows the drive box. However, the airborne radioactivity sampler for the

workers was positioned at a distance from the workers. The inspector

concluded that the airborne radioactivity sample being collected during the

work activity was not representative of the workers breathing zone in that:

-

The sampler was located upstream of the flow of air relative to

workers.

-

The sampler was not located as close as possible to the workers (the

sampler was located about 5 feet away).

-

Workers periodically placed their heads and upper bodies inside the TIP

drive box between the source of contamination and a portable

ventilation system. (Levels of radioactive contamination in the TIP

2

drive box ranged up to 14 millirad /hr per 100 cm . See Figure 5)

-

At least one worker positioned himself between the source of

contamination and a portable ventilation system. The air sampler was

upstream of the worker and portable ventilation system.

The inspector noted that Radiation Protection Procedure HP-213, Airborne

Radioactivity Survey Techniques, Revision 9, states in Section 6.1.2, that

ventilation flow paths shall be considered while sampling the breathing zone

and that the sample is to be located as close to the worker as possible without

.

31

,

interfering with his work. Based on the above, the inspector concluded that

ventilation flow paths were not adequately considered and the sample was not

located as close to the workers as possible. This observation was considered

an apparent violation. (50-352/93-04-03)

The inspector further noted that 10 CFR 20.201 requires that' surveys be

performed that are necessary and reasonable under the circumstances to

evaluate the radiation hazartis present and comply with 10 CFR Part 20.

10 CFR 20.201(a) defines a survey as an evaluation of the radiation hazards

present and states that when appropriate, such evaluations include

measurements of the concentrations of radioactive material present. The

i

inspector noted surveys were necessary and reasonable to ensure compliance

with the respiratory use provisions and the exposure assessment provisions of-

10 CFR 20.103.

The following additional matter was identified:

-

The inspector reviewed workers re-installing control rod drive position

,

indicating probes (PIPS). The inspector noted that the radiation work

permit that the workers were working under did not identify re-

installation of PIP probes as a " Task" to be performed. .Their

'

maintenance work request did identify the activity. The inspector's

review of the licensee's radiation work permit procedure indicated that

the procedure did not provide explicit guidance as to the scope of work

,

to be authorized to be performed under a radiation work permit. The

f

procedure also did not identify what should be entered under the RWP

" Task" section of the RWP.

The above observations and discussions with personnel indicated it was

unclear what level of detail was needed for the RWP work task

description. This was considered a program weakness.

9.0

Exit Meetings

i

The inspector met with licensee representatives (denoted in Section 1.0) on

January 22, February 3, 8 and 12,1993. The inspector summarized the purpose,

scope and findings of the inspection.

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Figure 3

Pa e No.

1

RESULTS OF UNIT 2 TIP TUBE SURVEYS

SORTED BY R0W

January 30, 1993

TIP

Contact Data

Contamination

Tube

Drive

Core

On Tube Ends

Inside Tubes

Row

Box

Location

(mrad /hr)

(dpm/Q-tip)

Comments

A

B

08-41

-

15k/40k

A

08-49

-

8k/6k

A

B

08-33

-

20r,/40k

A

B

08-17

24/40

200k/150k

A

B

08-25

8/-

80k 40k

B

A

16-49

-

45k 30k

1 Sli ht band

B

A

16-41

Bf 3

24k 80k

1 Sli ht bend

B

16-33

16/8

45k 15k

1 S14 ht bend

B

B-

16-17

8/ -

25k 8k

1 S11 ht bend, 1 Coupling:

B-

A-

16-57

-

26k 18k

B

16-25

-

24k 15k

2 Slf.ght bends

8k/ k

1 Singht bend

1 Coupling.

8/

/320

B

C

16-09

6000

560 mrad

Several slighf. bonds

C

E

24-41

6

4k

1 S11 ht bend

.1 Coupling

C

24-25

-

1 S11 ht bend, ling

6

16k

C

24-09

-

14 Ben

1 Coup

12

8k

C

24-17

-

C

B

24-33

8/-

28

10k

1 Sligbt bend

30k 35k

C

A

24-57

-

12k 25k

C

A

24-49

-

D

E

32-49

24000/12000

100

mrad

D

A

32-57

6k 5k

,

D'

C

32-25

8/-

6k 4k

1 Slight bend

D

C

32-09

-

5

4k

1 Coupling

D

C

32-17

8/16

3

3k

1 Cou ling

D

C

32-33

80/40

32 mrad

1 Sli ht bend

D

E

32-41-

1000/160

88 mrad

2 Sma 1 bends

E

C

40-09

-

8k/10k

1 Coupling

l--

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D

40-17

-/16

80k 120k

E

D

40-25

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20k 80k

E-

D

40-33

-

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'

L

E

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120 /300k

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1 Slight kink 3'

from end

E

A

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-

,

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!

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A

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-

F

D

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-

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30

12k

l

F

D

48-17

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l'

F

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-

20

16k

26

18k

.

F

D

48-33

-

l

F'

E

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12 48

88 -

ad

800-mrad /hr on' powder in bag

'

F

E-

48-49-

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1 7 Rad /hr on powder.in bag

G

E

56-41

13 /16

130k/130k

Twisted

G

E

56-33

-

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1 Slight bend

G

D

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12

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Figure 4

Page No.

1

'02/01/93

RESULTS OF UNIT 2 TIP TUBE SURVEYS

SORTED BY DRIVE BOX

January 30, 1993

TIP

Contact Beta

Contamination

Tube

Drive

Core

On Tube Ends

Inside Tubes

Row

Box

Location

(mrad /hr)

(dpm/Q-tip)

Commer*.s

A

08-49

-

8k/ k

45k 30k

1 Slight bend

B

A

16-49

-

B

A

16-41

8/8

24k 80k

1 Slight bend

B

A

16-57

-

26k 18k

30k 35k

C

A

24-57

-

C-

A

24-49

-

12k 25k

6k/ k

D

A

32-57

-

24k/30k

1 Slight kink 3'

from end

E

A

40-49

-

8k/20k

E

A

40-57

-

A

B

08-41

-

15K 40k

20k 40k

A-

B

08-33

-

A

B

08-17

24/40

200 /150k

80k 40k

8/ 8

A

B

08-25

16/

45k 15k

1 Sli ht bend

B-

B

16-33

B

16-17

8/-

25k 8k

1 S14 ht bend, 1 Coupling

24k 15k

2 S11 ht bends

B

16-25

-

C

B

24-33

8/-

28k lok

1 Sln ht bend

B

C

16-09

8/-

8k

k

1 Sla ht bend,

Coupling

C

24-25

-

6

4k

1 S14 ht bend

1 Slidht bend, lino.1-Coupling

C

24-09

-

6k 16k

1 Bend [1t bend 1 Coup

C

24-17

-

12 /8k

'

1 Slig

D

C

32-25

8/-

6

4k

Sk 4k

1 Coupling

D

C

32-09

-

D

C

32-17

8/16

3k 3k

1 Coupling

D-

C

32-33

80/40

32 mrad

1 Slight bend

E

C

40-09

-

8k/10k

1 Coupling

G

D

56-17

-

10k 10k

1 Slight Dend

12k 18k

G

D

56-25

-

26k 18k

F

D

48-33

-

E

D

40-17

-/16

80k 120k

E

D

40-25

-/8

20k 80k

E

D

40-33

-

40k 30k

F

D

48-09

-

-20k 24k

F

D

48-17

-

30k 12k

20k 16k

F

D'

48-25

-

C

E

24-41

6000/320

560 mrad

Several slight bends

D

E

32-49

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1000 mrad'

D-

E

32-41

~1000/160

88 mrad

2 Small bends

G

E

56-41

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130k/130k

Twisted

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1 Slight bend

-G

E

56-33

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F*

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80. mrad

1.2 Rad

F

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12 48

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E'

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>

.masmally beopento the public."

.

!

,

Hewever.toComadsehenhas decided

~i

toimplementa mealpeuyento

dessemisewhoshertoseeistata the

cenemtpelky witirsegard to -

enforcement esaferseems or.to adopt a

<

'

28w paikythat wenid allow sonst ;

TWre>VeerTrM W 9er

enfassement esoferomeen to be open io

1

'

Condesting r.1peaEnfereement

attsedsmenby alimembersof the public. -

l

consereescarnesysessensent

Feiky h

amusenNr aer .pt.a y

,

pg,g3,,

c

m

Comedenha ,

- "*"

1heIGC le 6-pla===.a.g a two-year

- J

trialpayen to aGew public

sumenesv TheNedeseRegelsemey

elusenettenof selected enforcement

r = ms

s== p m Clieteostas ele pokey eselssemene.The NitC wGI monitor the

'

steam memaemtheimplementeilseof a

P'88'en and detesmine wintiwr io

two year trial paspese es essw antamad establish a pommensetpolicy for .

-

enferoament essessemous to be span te

sendoseles

enfemument

attuadcoesby su members of the .

. ***Iunene

se en aseosoment of

generetpuhuc.This peNcy statement

' the feBowlegesteele _

describes the twoyeartrialpeepean

(t) Whelber the foot that the -

andledenne the publicof how to get

condammes wee opsaimpsoned the .

,

infensatiesse

spea

' NilC's shikty to esadent a sneeningful :

soferoament

osademons and/or mpA====t the NRCs

a

oaves:'fhis trialproyenteM on

'"I'""""8 P'*8""

July to. test,widle sommente se the

(3)Whetherthespeaconference =

propen ese beag suceived.Subsek

impacted the basesse's participation in

aa====to en er tiefere the compieden

thecad"emam

of tin treetinngres edadeled for July -

(s)Whetherthe NitCexpended a

St. seer. r'a====ea received after tids

a%=me==* emenet of resources in '

date welbs considered if it is practical

. to do me, but the G "to de able to

maldag the confeeence public: and'

(4)m exeset of publicinterest E

assure e===M-'stion only for commente .

received on or before this date.

opening the enforcement conference,

-

.

. - .

.

- - -

.

.-

.

. .

.

f.nclosure 2

Pd90 2 01 4

_

!

oL g No. 223 / Mday, Jidy la N 'gh

as

Federal Register u

.

..

-

t cissede rar seiseeingOpse

three c

1 of hoennese wGlbe

subjed to penemmel eczoenies.thet

.

gefassement ch

comenerdal operating reactora,

eigen, beamere, poseers. etc. not larger

be

hospitA.and other haveneeen, whide

thea ts" be ,

'i and that

7

will consist of the t===ining types of

disrupthe y====a sney be removed.

licensees.

Each reglemal adbo wiH swmema. to

oPea

. _

2a

W

lie tahan esainst as

IL A

- Open Beforcement

cadeQderoames conference

indivedmal, or if the act6en, thoesh met

Confusences '

yl

"

,

alturne

[gasa ne an

As soon as itle deteradned that an

wGl aa-Ha== to be a mes&is h

enforcement conference wGI be open to

b NRCand the beenees. Whus b

4

._ _ m _.

public oboarvation. the NRC wG1 orally

enforcement osafersece le open for

[

-g

h*

a tify the licensee that the enforcement puhuc observedea, h is am open for

involved {"kd conf: ~;.e-m wpen to p bue

pobge pe,en, sue ,

!

. hatabeIdivkl

oburvation as part of the agency's tdal

Pereens attending open enforweient

t

Prment

Program and send the Boonsee a copy of conferomoes are remiaM ed (1) b

(3)le basedonthe Sadings danNRC &le Fdud Regisawmodce ed paena swmgg

Once ofImmdgjenomejogsoport;or

the program.uoenmes wm be asked to egm

e,.,g

.e dg P"e

p[ll?e.eg g,g,,Inden or owm 6e -'

dule an

d-ge,ser w any,eeews

-

atinists the member of parecipante M

funbarseetow and may be subject to

-' =d-

ige

,aorbi,bcouidbe

m_ed

so that the NRC can sche

enferosmos aedom and(2) &e

.

Eniwamen},,,

inwhg

Nh,

"

appropetan*

NR

t

g g

overeupossess wGlbe open assuming

h

pen enforcement conferen,== or the

heebeen

Aetd-_t :'g:::l=d

,g ,i taw a= a - a- a *

iTre*e "rifrM.' *Illll'd ",, beuef,.

-

.

.e

1

"

" " " ' " " * "

en,.r m t.o e.In additi.m.be

edo,_=. ca.fere. css to .nce opene , abbe

wH 6e

in &ie modos. perms

Indiv6dael's nam

The NRC latende to annou

gee,- <e

- = a--

.

me.oes w

cpen to the pddio if the conference wGI normauy at least to working days in

span ht mderaces

8"m be

ida - o.,oamer e

be. conducted.by telephone or the

. .e

. be.au.ta m .

edvance.of t,he o.forcement conference

en

w

eo

mg .-

e*= wa- -mme- --Fooar

th,o,.gh . css ,oetu t. .e ,s

rei. d ,em an u.s.a.e ef.e m ,.

n No

"~

" ."."e' d .' 1 T t, $ '

T ;e i ,a we

22ll"a**"Cfww.rm

R

,e

O'***' d **

I

II

,

enforcement conferences wtB not be

(3) Toll-free electraalc belions board

h and caseidero6an,

opentothepublictaspedalcesse

wbenegoodseems hasbeen aboom after

establishanentof thetoBitw

Deled as assiMils han, een rih day of July

beleedes thebeneSt of puhuc

mesesse eyseases, the public may anil

test.

cbeareemos agalast thepetential hopect (Stn) 4es 4r32 to 48=8a a reeertling of

for en Hadser Raedsamrys'-mo.

on the assacre enfermemmet action in a upanaeng spea enforesument

%sment 0 Oinv

particularcase.

confer ==a== De NRC wEl tesse another s.creearyetde <*-m.

- De NRC wG1 strtve to conduct open

Fedomi Regletar m.Atee after the tou-free p Doc.so-sense rund 74 es:a4s aM

enforcement onaferences dartas the -

mesease erseems are-dh

esauses re e

two year trial progress in accordamos

To endet the NRC h seeddag

with the fauseus three goals:

a

to arrangemente to ag. pert

(1) .t .

=- dyas perant of au

pu ucobservenenetenseseement

m

eligible amieroommes confeemose

conferesses,endwiduale sannessed in

--

c demed by esNRCwCIbe open for

attendtag a panlaster enformnemt

puhuc beernoas

ca.f.e o.abeeldmostr sins. ded

CorreCilOnS

'ed"d **'

e

v

(2) At Isset ame open seiertement

id-nen=d in the noseng action

conference wd1 be conductedia each of anneandag the open enforcement

'

vel.1sr, No. tse

the reponalomcas:and

. confereses ao later thea Sve busiasse

Frtder. Idy tr. toes

(3)Open enlomassatsemieresses

days pr6er to the enforeneeset

wiu be conductedwit avenetyof the

confersone.

NUCLEAM HEtKA.ATORY

types of heenseen.

U

of Open Entwomment

Cotth81gg8088

To evoid poten6albianla the

Corderences

-

selection process and to attempt to meet

the three goele stated abees,every

in eooordemos with cement proctice.

Ttoo Yner Trtal program for-

fourth obsible safemament eenierence

enforcement conferences will continue

Censluctng OpenN

to norunnu be held at the NRC tagia 1

Conferenose; posey Statement

involving one of three categories of

r

bcensees wGimariseur be span to the

omces.Membere of the pubhc wGl be

Comredan

pubBc dertog the trial propea.

sllowed access to the NRC regional

However,in came where there le en

omos to eetend open enlare== ant

la notice dar===at 92162s3 bWng

ongotag edtudicatory proceeding with

conferences in accordance with the

on page Mrs2 h es leeue GM.

one er amore totervenore, enforcement

" Standard Opereting pmda For

}dy.181est on page 307t2.in &e

ww=d cohena.ander sans,

conferwoons lavolving teones related to

Providing Security Sapport For NRC

b subject metteraf the seemag

Hearmge And Meetings" pubhehed

la the fifth Hoa.,, July 11.19e2"

,

edjudiesdos mey also be opened.For

November,1,1 set (56 l'R Sc51). Thege

reed ") sly it im".

b purposes of this trialprogram, the

procedures provide that visitors mey be

- u-a came u

e

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.

- -

-

- .

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ML20034F599

Text

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