ML20036C318
| ML20036C318 | |
| Person / Time | |
|---|---|
| Site: | Palo Verde  |
| Issue date: | 06/08/1993 |
| From: | Reese J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | Conway W ARIZONA PUBLIC SERVICE CO. (FORMERLY ARIZONA NUCLEAR |
| References | |
| NUDOCS 9306160100 | |
| Download: ML20036C318 (2) | |
See also: IR 05000528/1993003
Text
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UNITED STATES
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NUCLEAR REGULATORY COMMISSION
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REGION V
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1450 MARIA LANE
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WALNUT CREEK. CAUFORNIA 94596-5368
'JUN - 81933
Dockets 50-528, 50-529, and 50-530
Arizona Public Service Company
P. O. Box 53999, Sta. 9082
Phoenix, Arizona 85072-3999
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Attention:
William F. Conway
Executive Vice President, Nuclear
Thank you for your letter, dated May 25, 1993, in response to our Notice of
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Violation issued by letter, dated April 27, 1993.
Your response informed us
of the steps you have taken to correct the items we brought to your attention.
Your corrective actions will be verified during a future inspection.
Sincerely,
&
Jam
H. Reese, Chief
f acilities Radiological Protection Branch
cc:
Mr. Steve Olea, Arizona Corporation Commission
James A. Beoletto, Esq., Southern California Edison Company
Mr. Charles B. Brinkman, Manager, Washington Nuclear Operations
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Mr. Aubrey Godwin, Director, Arizona Radiation Regulatory Agency
Chairman, Maricopa County Board of Supervisors
Jack R. Newman, Esq. , Newman & Holtzinger, P.C.
Mr. Curtis Hoskins, Executive Vice President and Chief Operating Officer,
Palo Verde Services
Roy P. Lessey, Jr., Esq., Akin, Gump, Strauss, Hauer and Feld
Bradley W. Jones, Esq., Akin, Gump, Strauss, Hauer and Feld
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930626o200 9306os
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ADDCK 05000528
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Dockets 50-528, 50-529, and 50-530
Arizona Public Service Company
P. O. Box 53999, Sta. 9082
Phoenix, Arizona 85072-3999
Attention:
William F. Conway
Executive Vice President, Nuclear
Thank you for your letter, dated May 25, 1993, in response to our Notice of
Violation issued by letter, dated April 27, 1993.
Your response informed us
of the steps you have taken to correct the items we brought to your attention.
Your corrective actions will be verified during a future inspection.
Sincerely,
James H. Reese, Chief
Facilities Radiological Protection Branch
CC:
Mr. Steve Olea, Arizona Corporation Commission
James A. Beoletto, Esq., Southern California Edison Company
Mr. Charles B. Brinkman, Manager, Washington Nuclear Operations
Mr. Aubrey Godwin, Director, Arizona Radiation Regulatory Agency
Chairman, Maricopa County Board of Supervisors
Jack R. Newman, Esq., Newman & Holtzinger, P.C.
Mr. Curtis Hoskins, Executive Vice President and Chief Operating Officer,
Palo Verde Services
Roy P. Lessey, Jr., Esq., Akin, Gump, Strauss, Hauer and Feld
Bradley W. Jones, Esq., Akin, Gump, Strauss, Hauer and Feld
bcc w/ copy of letter dated May 25, 1993:
Docket File
Resident Inspector
Project Inspector
G. Cook
R. Huey
B. Faulkenberry
J. Zollicoffer
bcc w/o copy of letter dated May 25, 1993:
M. Smith
Region V/ ann
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May 25,1993
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U. S. Nuclear Regulatorf Commission
ATTN: Document Control Desk
Mail Station P1-37
-Washington, DC 20555
Reference:
Letter dated April 27,1993, from John B. Martin, Regional Administrator,
NRC, to W. F. Conway, Executive Vice President, Nuclear, APS
.
Dear Sirs:
Subject:
Palo Verde Nuclear Generating Station (PVNGS)
Units 1,2, and 3
Docket Nos. STN.50-528/529/530
Reply to Notice of Violation (NRC Inspection Report
50 528/529/530/93-03)
_ File: 93-070-025
Arizona Public Service Company (APS) has reviewed NRC Inspection Report 50-528/529/
530/93-03, and the Notice of Violation, dated April 27,1993. Enclosure 1 to this letter is
a restatement of the four violations discussed in the Notice of Violation. . APS' response
to the Notice of Violation is provided in Enc!osure 2.
APS considers each of these violations to be serious. Significant effort has been invested
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to identify and address the root causes of these violations, and other performance issues
of the Radiation Protection Department at PVNGS.
Enclosure 3 provides the results of APS'internalinvestigation of this event. As discussed
in Enclosure 3 and during the March 18,1993 Enforcement Conference, the primary root
cause of this incident was that Radiation Protection Support Services (RPSS) Department
activities were not always controlled with the same diligence, by Radiation Protection (RP)
Management, as Operations and Maintenance activities were contretied. APS has
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U. S. Nuclear Regulatory Commission
ATTN: Document Control Desk
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Reply to NOV (NRC Inspection
Report 50 528/529/530/93-03)
Page 2
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developed broad based corrective actions to prevent recurrence. The results of the
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corrective actions, thus far, have been positive. APS Management will closely monitor the
implementation and effectiveness of the corrective actions to assure the improve
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performance is sustained.
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Should you have any questions, please call Thomas R. Bradish at (602) 393-5421.
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Sincerely,
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WFC/IRB/RKR/rv
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Enclosures:
1. Restatement of Notice of Violation
2. Rep!y to Notice of Violation
3. Results of APS'internalInvestigation
cc:
J. B. Martin
J. A. Sican
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STATE OF ARIZONA
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COUNTY OF MARICOPA )
1. W. F. Conway, represent that I am Executive Vice President - Nuclear, that the
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foregoing document has been signed by me on behalf of Arizona Public Service
Company with full authority to do so, that I have read such document and know its
contents, and that to the best of my knovdedge and belief, the statements made therein
are true and correct.
NW
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W. F. Conway
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Sworn To Before Me This 1b Day Of ~WIRA>
,1993.
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kt]nt n_,,b. & /b
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Notary Public
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My Commission Expires
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ENCLOSURE 1
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RESTATEMENT OF NOTICE OF VIOLATION (EA 93-039)
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NRC INSPECTION CONDUCTED
J ANUARY 11,.1993 THROUGH FEBRUARY 12,1993
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NRC INSPECTION REPORT 50-528/529/530/93-03l
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RESTATEMENT OF NOTICE OF VIOLATION (EA 93-039)
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During an NRC inspection conducted on January 11 through February 12, 1993,
In accordance with the General
violations of NRC requirements were identified.
Statement of Policy and Procedure for NRC Enforcement Actions," 10 CFR Part 2.
Appendix C, the violations are listed below:
A.
10 CFR 20.101(a) requires that the licensee limit the whole body radiation dose of
an individual in a restricted area to one and one quarter rems per calendar
quarter, except as provided by 10 CFR 20.101(b).10 CFR 20.101(b) allows a
licensee to permit an individual in a restricted area to receive a whole body
radiation dose of three rems per calendar quarter provided the dose when added
to the individua!'s accumulated occupational dose to the whole body does not
exceed the applicable limit and the individual has a completed Form NRC-4 or
equivalent record on file.
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Contrary to the above, on December 21,1992, the licensee did not limit the.whole
body radiation dose of an Individualin the Unit i radwaste truck bay, a restricted
area, to one and one quarter rems per calendar quarter and the conditions of
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10 CFR 20.101(b) were not met. Specifically, the individual received a whole body
dose of 2.455 rems during the fourth calendar quarter of 1992 without a completed
Form NRC-4 or equivalent record on fite.
10 CFR 20.201(b) requires that each licensee make such surveys as may be
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necessary to comply with the requirements of Part 20 and which are reasonable
under the circumstances to evaluate the extent of radiation hazards that may be
present. As defined in 10 CFR 20.201(a), " survey" means 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.
Contrary to the above, as of December 21, 1992, the licensee did not make
surveys to assure compliance with the limits of 10 CFR 20.101 for the radiation
exposure to the whole body. Specifically, during the fill head removal and capping
of the high integrity container, the radiation hazards incident to removing the resin
fill head and the worker putting his hand in the fill hoie were not evaluated.
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C.
10 CFR 20.202(a)(3) requires that each licensee supply appropriate personnel
rnonitoring equipment to, and require the use of such equipment by, each
individual who enters a high radiation area.
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Contrary to the above, on December 21, 1992, the licensee did not cupply
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appropriate personnel monitoring equipment to a contract worker who entered a
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high radiation area. Specifically, the dosimetry issued to the worker was not
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appropriate in that the portion of the worker's body receiving the highest whole
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body dose, the left upper arm, was not monitored.
D.
Technical Specification 6.11.1 states, " Procedures for personnel radiation
protection shall be prepared consistent with the requirements of 10 CFR Part 20
and shall be approved, maintained, and adhered to for all operations involving
personnel radiation exposure."
1.
Procedure 75PR-0RP03, Revision 2, "ALARA Program," states:
3.8.2 Station modifications or equipment changes which may
affect radiation exposure shall receive an ALARA review
based on Regulatory Guide 8.8.
Contrary to the above, in January 1992, the licensee changed radwaste
disposal containers for high radiation area applications from metal Enviral!oy
to polyethylene high-integrity containers (HIC), a modification which could
affect radiation exposure, and did not perform an ALARA review of this
equipment change.
2.
Procedure 75PR-9ALO3, Revision 3.00, "ALARA Pre-job Planning, contains
instructions for the Radiation Exposure Permit (REP) preparer to follow as
part of the pre-job planning process. Section 3.1, " Pre-Job Planning,
makes the following statements:
3.1.2 Determination of Job Scope
3.1.2.1
The job scope should be determined such that the
REP, when written, adequately addresses specific
radiological conditions and protective requirements.
Section 3.1, " Pre Job Planning," further states:
3.1.6 RP Interface with Planners / Work Group
3.1.6.2
Address aspects of the job that might affect personnel
exposures such as body position, special tools, etc.
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Contrary to the above, on December 15 - 21,1992, a work planner did not
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determine the scope of the work to be performed and did not communicate
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with the work group so as to address aspects of the job that might affect
personnel exposures, when preparing REP 192-1059 A. Specifically, the
planner was not aware that the job involved working in the prone position
on top of the HIC or that the worker would be inserting his hand into the
HlC's resin fill hole (the location of the highest exposure rates).
Procedure 75RP 9RP02, Revision 2.00, " Radiation Exposure Permits,"
3.
Section 2.1.1 provides that RP Supervision / Management are " responsible
for required reviews and approvals of REPS [ radiation exposure permits)
per Appendix F, the Job Hazard Evaluation System (JHES) Category
Index."
Appendix F states that Category 1 tasks:
... are considered the most radiologically hazardous work that we
encounter.
When REP's are written for Category 1 work, the
Manager, Unit RP shall sign the approval section of the REP. The
Manager, RP Operations shall also review and sign the REP.
Contrary to the above, the Unit RP Manager's approval signature did not
appear on REP 1-921059-A on December 21,1992, when the REP was
issued, even though the job was classified as JHES Category 1.
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Section I of the ALARA Review Form states that when an REP meets JHES
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Category 1 criteria, a Site ALARA review is required.
Contrary to the above, on December 21,1992, the Acting ALARA/ Work
Control Supervisor did not forward REP package 1-921059-A, a JHES
Category 1 REP, to Site ALARA for review.
5.
Section I of the ALARA Review Form states that when an REP meets JHES
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Category 1 criteria, a Site ALARA review is required.
Procedure
75RP-9RP02, Revision 2.00, " Radiation Exposure Permits," states in Section -
3.2, " REP Preparation," the following:
3.2.21
RPS - The signature in the RPS Block verifies that the controls
identified on the REP ensure adequate radiological protection
and that the REP is a complete document (e.g., required
ALARA Reviews are complete, etc.)
Contrary to the above, on December 18,1992, the Acting ALARAN/ork
Control Supervisor signed the RPS block on REP 1-92-1059 A prior to Site
ALARA review being completed.
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Procedure 75RP 9ALO3, Revision 3.00, "ALARA Pre Job Planning," states:
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3.4.3 ALARA Reviews (Section 2) require review and approval by
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the Manager, RP Operations.
Contrary to the above, the RP Operations Manager did not review or
approve the Site ALARA review on REP 1921059-A prior to the REP being
issued on December 21,1992.
Procedure 76CP 9NP06, Revision 2. " Operating Procedure - Resin Drying
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(Dewatering) System," requires in Section 5.4.1 that workers " Follow all
REP 192-1059-A included the following
instructions on the REP."
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Instructions to the workers performing the fill head removal:
"A/S [ air sample] during fill head removal."
" Remotely install lid w 'T Handle.' (sic)"
"No work other than described above will be permitted on this
REP"
Contrary to the above, on December 21,1992, workers did not use the 'T
Handle" to insta!! the HlO lid and no air sample was taken while performing
1-92-1059-A. Additiona!!y, RP Technicians
the work authorized by REP
working under this REP performed a resin sample split, work not authorized
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under REP 1-92-1059 A.
Procedure 75RP-9RP10 Rev.1.2, " Conduct of Radiation Protection
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Operations," states the following RP Senior Technician job coverage duties:
2.2.4 Be aware of activities in the designated area of responsibility,
provide adequate supervision and radiation protection
surveillance to ensure the appropriate procedures are
followed, planned precautions are observed, and all potential
radiation hazards that develop or are recognized during the
operation are addressed in a timely and appropriate manner.
Additional RP Senior Technician duties are listed in REP 1-92-1059-A,
including the duty to provide " Continuous covg. (coverage) during any
HlC/fi!! head move and LHRA entry." Continuous coverage is defined in
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75RP-9RP02. Revision 2.00, " Radiation Exposure Permits " as:
4.1.9.1
A qualified RP technician with a dose rate monitoring
device who is responsible for providing positive control
over the activities within the area.
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The RP Senior Technician is also charged with the authority to stop work
as defined in 75RP-9RP02, Revision 2.00, " Radiation Exposure Pcrmits":
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This authority will be exercised by qualified RP
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4.1.12.1
representatives when radiological conditions and job
practices could endanger the workers or could violate
NRC regulations, station procedures, or Al. ARA
controls for the job.
Contrary to the above, on December 21,1992, the primary RP Senior
Technician did not exercise his stop work authority when unexpected
radiation hazards were recognized while performing work authorized by
REP 1-92-1059-A. Specifically, the RP Senior Technician did not stop the
job when he recognized that radiation readings were higher than expected
after the resin fill head was raised above the HIC. The RP Senior
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Technician also failed to ensure that planned precautions to reduce
personnel radiation exposure were followed, in that remote tools were not
used and an air sample was not taken.
Procedure 76CP-9NP06, Revision 2, " Operating Procedure - Resin Drying
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Dewatering) System," contains instructions for the workers performing the
resin fill head removal and capping of the HIC under REP 1-92-1059 A.
Procedure 76CP-9NP06 states:
6.8.2 Install the container lid in accordance with the container
instruction manual or procedure.
Insure that the lid is
installed to a leak tight seal.
Attachment H, Resin Drying Process Memo and Process Data Sheet,"is an -
official record that documents the entire resin transfer process from fi!!ing
the HlC and drying the resin to capping the HIC.
Section VI, " Closure," of Attachment H contains the sign-off check list for
closing the HlC and requires the worker's initials verifying that the
" Threaded lid [was] torqued to min. 50 ft-lbs (if applicable)" using a
calibrated torque wrench.
Contrary to the above, on December 21,1992, a worker performing work
authorized by REP 1-92-1059-A installed the HIC lid for final closure by
hand without the use of a torque wrench, which is required for final closure,
to determine if the minimum torque required was achieved.
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10.
Proceduro 75RP-ORP03, Revision 3.00, "ALARA Program," Section. 2.15
provides in part that Work Group Supervisors are required to supervise
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jobs "to ensure that maximum benefit is derived from necessary worker
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radiation exposure" (2.15.1), and "participat[e] in pre-planning of work to be
performed in Radiological Controlled Areas and Post Job Reviews" (2.15.4).
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Contray to the above, on December 15-21, 1992, the supervisor
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responsible for the work group performing the fill head removal job did not
participate in the pre-job planning or pre job briefing, and was not present
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to supervise during the actual job performance.
This is a Severity Level ll1 problem (Supplement IV).
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ENCLOSURE 2
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REPLY TO NOTICE OF VIOt.ATION (EA 93-039)
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NRC INSPECTION CONDUCTED-
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JANUARY 11,1993 THROUGH FEBRUARY 12,1993
NRC INSPECTION REPORT 50-528/529/530/93-03
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REPLY TO VIOLATION A (50-528/93-03-05)
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fLdmission Or Denial Of The Alleaed Violation
APS admits the violation.
Reason For The Violation
The APS investigation of this incident determined that the primary root cause of the
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overexposure was that Radiation Protection Support Services (RPSS) Department
activities were not always controlled with the same diligence, by Radiation Protection (RP)
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Management, as Operations and Maintenance activities were controlled. The investigation -
evaluated the barriers that should have prevented the radiation exposure in excess of the
limits of 10 CFR 20.101(a). The barriers included: 1) job scope understanding; 2)
Radiological Exposure Permit (REP) preparation; 3) Al. ARA planning and control; 4) pre-
job briefing; and 5) control of work in the field. These barriers were ineffective-in
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preventing this incident, due to RP Management's less than adequate diligence in
controlling RPSS activities. For this specific violation, the worker did not sign his Form
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NRC-4 when notified that it was ready to be signed.
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Corrective Steps That Have Been Taken And Results Achieved
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Enclosure 3 provides detailed corrective actions, including appropriate management
controls,which have been taken to correct the identified causes of the issues surrounding
this incident.
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in addition to the worker, the worker's supervisor is now notified when a worker's Form
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NRC-41s ready to be signed. APS has also lowered the allowed quarterly exposure to
300 mrem (limit can be raised only with management approval). These actions should
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ensure that the quarterly dose limit of one and one quarter rems, without a completed
Form NRC-4, will not be exceeded.
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Corrective Steps That Will Be Taken To Avoid Further Violations
The actions described above should prevent further violations of this type.
Date When Full Compliancp_Will Be Achieved
Full compliance was achieved on December 21,1992, when the individual signed his
Form NRC-4.
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REPLY TO VIOLATION B (50 528/93-03-031
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Admission Or Denial Of The Alleced Violation
APS admits the violation.
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Reason For The Violation
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The failure to conduct a radiation survey during the fill head removal and capping of the
poly high integrity container (HIC), was a result of the REP preparer not being fully aware
of the job scope, incorrectly evaluating the dose rates against previous similar evolutions,
and not identifying special RP monitoring requirements in the REP.
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Corrective Steps That Have Been Taken And Results Achieved
REP pre job planning procedures have been revised to define review requirements. RP
Technicians have been briefed on this event. Interviews of RP personnel by APS OA and
RP management have determined that these briefings were effective.
Appropriate
disciplinary action was administered to the REP preparer.
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Corrective Steos That Will Be Taken To Avold Further Violations
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The development of model REPS, similar to those being used for refueling outage
activities, will provide additional guidance for evaluating survey data and performing
surveys during the performance of work activities.
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Date When Full Compliance Will Be Achieved
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Full compliance was achieved on December 21,1992, at the conciusion of the work when
the survey was no longer required.
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REPLY TO VIOLATION C (50-528/93-03-041
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A_dmission Or Denial Of The Alleged Violation
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APS admits the violation.
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Reason For The Violation
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The failure to properly provide personnel monitoring equipment to monitor the portion of
the worker's body receiving the highest whole body dose was a result of the REP '
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preparer and RP Technician covering the icb not being fully aware of the job scope and
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the need for head and upper arm dosimetry.
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Corrective Steps That Have Been Taken And Results Achieved
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APS has implemented an RP Manager and Supervisor internal self assessment program,
established criteria for job site supervisory involvement, and clarified the requirements
for RP Senior Technician and RP Supervisorinvo!vementin pre-job briefings. Appropriate
disciplinary action was administered to the REP preparer and RP Technician.
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Corrective Steps That Will Be Taken To Avoid Further Violations
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The development of model REPS, similar to those being used for refueling outage
activities, will provide additional guidance for evaluating survey data and work scope to
determine dosimetry location requirements.
Date When Full Comollance Will Be Achieved
Full compliance was achieved on December 21,1992, at the conclusion of the work whe
the personnel dosimetry requirements were no longer required.
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REPLY TO VIOLATION D (50-528/93-03 02)
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Admission Or Denial Of The Alleaed Violatiort
APS admits the violation.
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Reason For The Violation
This violation identified ten examples of failure to follow procedures for personnel radiation
protection as required by Technical Specification 6.11.1. The APS investigation of t
incident determined that the primary root cause of this incident was that Radiation
Protection Support Services (RPSS) Departrnent activities were not always controlled w
the same diligence, by Radiation Protection (RP) Management, as Operations and
Maintenance activities were controlied. The investigation evaluated the barriers that
should have prevented this incident. The barriers included: 1) job scope understanding;
2) Radiological Exposure Permit (REP) preparation; 3) ALARA planning and control; 4
pre-job briefing; and 5) control of work in the field. These barriers were ineffective in
preventing this incident, due to RP Management's less than adequate diligence in
contrc!!ing RPSS activities.
The investigation also identified causal factors which
contributed to the failure of these barriers, including the failure to follow procedures
discussed in this violation. The investigation identified a number of contributing causes
for the failure to follow procedures. These included: 1) lack of sensitivity to short high
dose rate jobs; 2) tack of a questioning attitude; 3) lack of planner involvement in field
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activities; 4) overconfidence due to f amiliarity with work; 5) lack of supervisor involvement;
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and 6) unclear management expectations for RPSS activities.
Corrective Steps That Have Been Taken And Results Achieved
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APS has implemented an RP Manager and Supervisor internal self assessment
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program, established criteria for job site supervisory involvement, and clarified the
requirements for RP Senior Technician and RP Supe'rvisor involvement in pre job
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briefings. These corrective actions include an emphasis on personal accountability and
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procedure compliance.
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Corrective Steps That Will Be Taken To Avoid Further Violations
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APS believes that the corrective actions discussed above should prevent further violations
of this type.
Date When Full Compliance Will Be Achieved
For example 1, full compliance was achieved on May 24,1993, when the ALARA review
for the change from a Enviratfoy HIC to a polyethylene HlO was completed. For
examples 2 through 10, full compliance was achieved on December 21,1992, at the
conclusion of the work when the REP was no longer required.
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Additional.tnformation
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Example 9 identified a procedure violation where the worker ". . , installed the HlO
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hand without the use of a torque wrench, which is required for final closure, to determ
if the minimum torque required was achieved," APS does not torque the HIC lid
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immediately following installation. Once the HIC lid has been torqued it is difficult to
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remove, Sinco the HlO lid may have to be removed to allow for sampling of the H!C
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contents, the HlC lid is norma!!y torqued (final closure) during final preparation for
shipping the HIC. The procedure sign-off checklist is left open until the torquing
completed and verified. Therefore, the worker did not, nor was he expected to, torque
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the HIC lid for final closure during the resin fill head removal and capping of the HIC.
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ENCLOSURE 3
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RESULTS OF APS' INTERNAL INVESTIGATION
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RESULTS_OF AP_S' INTERNAL INVESTIGATION
An APS Incident investigation Team (llT) conducted an integrated investigation of the
pedormance issues occurring during this incident. As discussed in the March 16,1993
Enforcement Conference, the investigation determined that the primary root cause of this
incident was that Radiation Protection Support Services (RPSS) Department activities
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were not always controlled with the same diligence, by Radiation Protection (RP)
Management, as Operations and Maintenance activities were controlled. Contributing
causes included weaknesses in RP Management follow up to correct identified problems
and lack of a critical self assessment culture within the RP organization.
The investigation evaluated the barriers that should have prevented the radiation
exposure in excess of the !!mits of 10 CFR 20.101(a). The barriers included: 1) Job
scope understanding; 2) Radiological Exposure Permit (REP) preparation; 3) ALARA
planning and control; 4) pre-job briefing; and 5) control of work in the field. These
barriers were ineffective in preventing this incident, due to RP Management's less than
adequate diligence in controlling RPSS activities.
Corrective actions have been implemented to provide improved management controls
over internal RP activities. These corrective actions include:
1) development and
implementation of an RP Manager and Supervisor internal self assessment program;
2) establishment of criteria for job site supervisory involvement; 3) Implementation of a
centralized AIARA planning organization; 4) revised REP and ALARA pre-job planning
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procedures to define signature and review requirements; and 5) clarification of the
requirements for RP Senior Technician and RP Supervisor involvement in pre-job
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briefings. Also, personnel involved in this incident were disciplined in accordance with
the APS Positive Discipline Program.
Additional corrective actions were identified to strengthen the barriers that should have
prevented this incident. These additional corrective actions include: 1) development of
model REPS for sensitive RPSS activities (these include resin transfers, filter transfers, and
dry active waste processing) similar to those already in use for refueling outage activities;
2) development of REP and pre-job briefing checklists: 3) training of RP Senior
Technicians and Supervisors on briefing techniques; 4) establishment of a centralized RP
job history program and a guideline for developing job history files (expected to be
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completed by July 31,1993); 5) incorporating the significance of body positioning and
retiance on a! arming dosimeters into continuing training for RP personnel (expected to
be completed by June 1,1993); and 6) briefing RP personnel on this incident.
APS Ouality Assurance (OA) has been monitoring the implementation and effectiveness
of the corrective actions for this incident. APS OA has verified that corrective actions
taken have been generally effective. In some areas, APS OA has identified weaknesses
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in corrective actions (e.g., weaknesses in criteria specifying supervisor job site
involvement, potential problem with the criteria for supervisor review and approval of
REPS, and weaknesses in the implementation of centralized ALARA review of REPS). In
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each case, RP Management has made improvements to the corrective cetions; to
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eliminat'e the weaknesses APS QA identified (procedures were revised to clarify
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requirements and RP Management provided guidance to eliminate potential problems and
weaknesses). APS OA fo!!ow up to the improvements to the corrective actions concluded
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that the improvements were effective.
APS OA also interviewed the personnel involved in this incident and verified that they
understood the personnel errors that contributed to this incident. Additionally, APS OA
conducted independent interviews of RP personnel and verified that the briefings on this
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incident were effective, and that RP personnel understood the cause of this incident. RP
Management has also conducted interviews of RP personnel to verify the effectiveness
of the briefings., it was concluded that the briefings were effective and RP personnel
understood the cause of the incident.
Finally, the PVNGS Off-Site Safety Review Committee (OSRC) performed an independent
assessment of this incident. The OSRC also concluded that the primary root cause of
this incident was that RPSS activities were not always diligently controlled by RP
Management.
Beginning in June 1993, APS will conduct an Organizational and
Programmatic (O&P) assessment of the RP Department. A part of the O&P assessment
will be to verify the effectiveness of corrective actions resulting from this incident.
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