ML20043D583

LER 90-020-00:on 900504,radwaste Operator Entered High Radiation Area W/O Dose Rate Meter,Alarming Dosimeter or Radiation Protection Technician Coverage.Caused by Personnel Error.Training Provided to operators.W/900601 Ltr

ML20043D583
Person / Time
Site:	River Bend
Issue date:	06/01/1990
From:	England L, Odell W GULF STATES UTILITIES CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-90-020, LER-90-20, RBG-32938, NUDOCS 9006080272
Download: ML20043D583 (4)

Text

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a GULF . ST/2TES . UTILITIES COMPANY HNfR9thD11A43N *0ST Of t tCE Box ;20 $f FRAN;tSv4LE L.OU$1AN4 707M ARE A CODE 6&4 f.M 6mh1 wo8%1 June 1,1990 RBG-32938 File Nos. G9.5, G9.25.1.3

.q U.S. Nu' clear Regulatory Ccmnission Document Control Dcak j washington, D.C. 20555 a Gentlemen:

River Bend Station - Unit 1 Docket No. 50-458 Please find enclosed Licensee Event Report No.90-020 for 1 River Bend Station - Unit 1. This report is being subnitted 7 pursuant to 10CFR50.73. '

Sincerely,

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Y1. . s Manager-Oversight River Bend Nuclear Group cc: U.S. Nuclear Regulatory Catmission 611 Ryan Plaza Drive, Suite 1000 Arlington, TX 76011 NRC Resident Inspector P.O. Box 1051 St. Francisville, IA 70775 INPO Records Center i 1100 Circle 75 Parkway L Atlanta, GA 30339-3064 l

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'" Personnel Failed to Follow Procedure Hhen 'Ihey Crossed A High Radiation Barrier, '

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-At 1500 hours0.0174 days <br />0.417 hours <br />0.00248 weeks <br />5.7075e-4 months <br /> on 05/04/90 with the reactor at 100 percent power (Operational Condition 1), a radwaste operator entered a high >

radiation area (HRA) without a dose rate meter, alarming dosimeter or radiation protection technician (RP Tech) coverage.

Also (under the same plant operating conditions), at approximately 1030 on 05/09/90 while conducting a scheduled high radiation area door check of door RW117-01, a contract security officer inadvertently crossed a high radiation area barrier without a dose rate meter, alarming dosimeter or a radiation protection technician. Since' these events constitute a non-compliance with Technical Specification 6.12.1, this report is submitted pursuant to 10CFR50. 73 (a) (2) (1) (B) .

The root cause of the actions of operator and the security officer is considered to be cognitive personnel error.

Training on radiation protection practices related to these events will be provided to plant operators. Operations and security personnel have been reinstructed on recognizing and complying with radiation caution signs, labels, signals and controls.

These events had no adverse impact on the safe operation of River Bend Station or on the health and safety of the public, th'J'"" "*

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0l 0 0l2 0F 0l3 av . . = w mimm REPORTED CONDITION At 1500 hours0.0174 days <br />0.417 hours <br />0.00248 weeks <br />5.7075e-4 months <br /> on 05/04/90 with the reactor at 100 percent power i (Operational Condition 1), a radwaste operator entered a high  !

radiation area (HRA) without a dose rate meter, alarming dosimeter or  ;

radiation protection (.RP) technician coverage.  !

i Also (under the_ same g lant operating conditions) , at approximately i 1030 on 05/09/90, while conducting a scheduled high radiation area door check of door RW117-01, a contract security officer inadvertently crossed a high radiation area barrier without a dose rate meter, alarming dosimeter or a radiation protection technician.

Technical Specification (TS) 6.12.1 requires that individuals entering j high radiation areas shall be provided with or accompanied by a dose rate meter, an alarming dosimeter or a qualified health physics technician.

These events were documented on Condition Reports 90-0395 and 0413 respectively. Since these events constitute a non-compliance with TS  ;

6.12.1, this report is submitted pursuant to 10CFR50.73 (a) (2) (1) (B) .

INVESTIGATION I The non-compliance by the radwaste operator occurred during the

-addition of walnut shell filter media to 1LWS-FLT1A. This i infrequently performed operation had never been performed by the radwaste operator and the exact location cf two manual valves was unknown to him. Following entry into the radwaste building 117 ft. .

valve gallery, the operator crossed a high radiation area boundary and continued to search for the manual valves. After approximately one minute, an RP technician entered the room and discovered him in the 1 high radiation area. The operator's exit dose was determined by reading the pocket dosimeter to be five millirems.

The root cause of the operator's non-compliance is considered to be cognitive personnel error resulting in failure to observe radiological postings. This is a violation of procedure RSP-0200 " Radiation Work Permits" and TS 6.12.1.

Investigation of the second event by security management personnel revealed that although the officer saw and recognized the high radiation barrier, she was so focused on completing the door check that she did not comply with the requirements of the barrier. The barrier was established across a radwaste building RW117 ft, passageway. After exiting the area the officer was questioned by a RP technician. During the conversation, the RP technician determined that the officer had unthinkingly crossed the barrier and that she was unaware of her pocket dosimeter reading prior to entry. The RP technician immediately conducted a dosimetry review, the results of g, o ~ .v. ........i.s

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0 10 0 13 0F 013 ne a . .wm a mma mw n.numm i which estimated the officer's dose to be zero. The root cause of the officer's actions has been determined to be cognitive personnel error.

GSU submitted LER 90-010 dated 04/19/90 concerning a similar event.

Neither the radwaste operator or the security officer had an opportunity to participate in the corrective-action outlined in the LER prior to the subject events.  ;

CORRECTIVE ACTION Training on radiation protection practices related to this event will be provided to plant operators to emphasize the importance of these requirements. The senior vice president, River Bend Nuclear Group, has issued to all site personnel a multi-step policy pertaining to radiation protection violations. The operator who crossed the high radiation area boundary has received additional counseling on this event.

For immediate corrective action, the security officer was relieved of H surveillance duty, interviewed and counseled on the details of this event and reinstructed on recognizing radiation caution signs, labels,- l signals and other controls. The seriousness of failure to follow procedures was re-emphasized to the officer and the officer has been i directed to always follow procedures when crossing radiation barriers. l The officer resumed her duties the following day, j

. 1 As of 05/14/90 security personnel have been briefed on the facts and I circumstances of this event. They have been retrained on recognizing and complying with radiation caution signs, labels, signals and controls. The training sessions were conducted jointly by security and radiation protection supervisors. Further, security supervisors and trainers will continue to periodically re-emphasize recognition and compliance with radiation caution signs, labels, signals and

-controls during work briefings and training sessions.

SAFETY ASSESSMENT These events did not involve any automatically or manually initiated safety system responses. The operator was the only person at the time to enter the high radiation area without observing the proper monitoring requirements. The operator's exit dose was 5 millirem by pocket dosimeter. According to her pocket dosimeter, the security officer received a zero millirem dose reading. These events had no adverse impact on the safe operation of River Bond Station or on the health and-safety of the public.

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