ML20045B940

Provides Response to Violations Noted in Insp Repts 50-528/93-03,50-529/93-03 & 50-530/93-03.Corrective Actions: Licensee Did Not Limit Whole Body Radiation Dose of Individual in Unit 1 Radwaste Truck Bay

ML20045B940
Person / Time
Site:	Palo Verde
Issue date:	05/26/1993
From:	Conway W ARIZONA PUBLIC SERVICE CO. (FORMERLY ARIZONA NUCLEAR
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
102-02522-WFC-T, 102-2522-WFC-T, NUDOCS 9306210293
Download: ML20045B940 (23)

Text

,yi s CORRECTED COPY Arizona Public Service Company P O DOX53999

• PHOLNIX AA! ZONA 85072-39W wwAM F CONWM 102-02522-WFC/TRB/RKR m eumgts- May 26,1993 U. S. Nuclear Regulatory 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

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: 93-070-026 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 Enclosure 2.

APS considers each of these violations to be serious. Significant effort has been invested 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'intemalinvestigation of this event. As discussed in Enclosure 3 and during the March 16,1993 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 controlled. APS has-180010 9306210293 930526 JU dh

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U, S. Nu'elear Regulatory Commission ATTN: Document Control Desk C. Reply to NOV (NRC Inspection ,

Report 50-528/529/530/93-03)

Page 2-b developed broad based corrective actions to prevent recurrence. The results of the corrective actions, thus far, have been positive. APS Management will closely monitor the implementation and effectiveness of the corrective actions to _ assure the improved performance is sustained.

Should you have any questions, please call Thomas R. Bradish at (602) 393-5421. i r

Sincerely. -

ihWA h

WFC/TRB/RKR/rv

Enclosures:

1. Restatement of Notice of Violation

2. Reply to Notice of Violation

3. Results of APS' Internal Investigation ]

cc: J. B. Martin J. A. Sloan L

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l STATE OF ARIZONA )

) ss.

COUNTY OF MARICOPA )

I, W. F. Conway, represent that I am Executive Vice President - Nuclear, that the 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 knowledge and belief, the statements made therein are true and correct.

lW

/ W. F. Conway

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Sworn To Before Me This M Day Of ~D9OM ,1993.

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LYrln. A0. b/3r/b / Notary Public My Commission Expires 9T1 a reh 'll, l99(o L

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ENCLOSURE 1 RESTATEMENT OF NOTICE OF VIOLATION (EA 93-039)

( NRC INSPECTION CONDUCTED JANUARY 11,1993 THROUGH FEBRUARY 12,1993 NRC INSPECTION REPORT 50-528/529/530/93-03 1

RESTATEMENT OF NOTICE OF VIOLATION (EA 93-039)

'( During an NRC inspection conducted on January 11 through February.12,1993, .

violations of NRC requirements were identified. In accordance with the " General 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 individual'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.

Contrary to the above, on December 21,1992, the licensee did not limit the whole body radiation dose of an individualin the Unit 1 radwaste truck bay, a restricted area, to one and one quarter rems per calendar quarter and the conditions of 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 file.

B. 10 CFR 20.201(b) requires that each licensee make such surveys as may be 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 hole were not evaluated.

C. 10 CFR 20.202(a)(3) requires that each licensee supply appropriate personnel monitoring equipment to, and require the use of such equipment by, each individual who enters a high radiation area. i I

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Contrary to the above, on December 21, 1992, the licensee did not supply appropriate personnel monitoring equipment to a contract worker who entered a C high radiation area. Specifically, the dosimetry issued to the worker was not appropriate in that the portion of the worker's body receiving the highest whole 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 Enviralloy to polyethylene high-integrity containers (HIC), a modification which could affect radiation exposure, and did not perform an ALARA review of this equipment change.

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( 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 l 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 PlannersAVork Grcup  :

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

( determine the scope of the work to be performed and did not communicate with the work group so as to address aspects of the job that might affect personnel exposures, when preparing REP 1-92-1059-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 ,

HIC's resin fill hole (the location of the highest exposure rates).

3. Procedure 75RP-9RP02, Revision 2.00, " Radiation Exposure Permits,"

Section 2.1.1 provides that RP Supervision / Management are " responsible-for required reviews and approvals of REPS (radiation expocure 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 1-92-1059-A on December 21,1992, when the REP was issued, even though the job was classified as JHES Category 1.

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4.Section I of the ALARA Review Form states that when an REP meets JHES 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 1-92-1059-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 '

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 ALARA/ Work Control Supervisor signed the RPS block on REP 1-92-1059-A prior to Site ALARA review being completed.

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6.' Procedure 75RP-9ALO3, Revision 3.00, "ALARA Pre-Job Planning," states:

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I 3.4.3 ALARA Reviews (Section 2) require review and approval by i the Manager, RP Operations. i Contrary to the above, the RP Operations Manager did not review or approve the Site ALARA review on REP 1-92-1059-A prior to the REP being issued on December 21,1992.

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7. Procedure 76CP-9NP06, Revision 2, " Operating Procedure - Resin Drying (Dewatering) System," requires in Section 5.4.1 that workers " Follow all instructions on the REP." - REP 1-92-1059-A included the following 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 install the HIC lid and no air sample was taken while performing the work authorized by REP 1-92-1059-A. Additionally, RP Technicians

{- - working under this REP performed a resin sample split, work not authorized under REP 1-92-1059-A.

8. Procedure 75RP-9RP10 Rev. 1.2, " Conduct of Radiation Protection 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 i 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. l Additional RP Senior Technician duties are listed in REP 1-92-1059 A.

including the duty to provide " Continuous covg. [ coverage] during any  ;

HIC /fillhead move and LHRA entry." Continuous coverage is defined in  !

75RP-9RP02, Revision 2.00, " Radiation Exposure Permits," as:

4.1.9.1 A qualified RP technician with a dose rate monitonng device who is responsible for providing positive control over the activities within the area.

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i The RP Senior Technician is also charged with the authority to stop work as defined in 75RP-9RP02, Revision 2.00, " Radiation Exposure Permits".-

4.1.12.1 This authority will be exercised by qualified RP representatives when radiological conditions and job practices could endanger the workers or could violate NRC regulations, station procedures, or ALARA 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 HlC. The RP Senior 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.

9. Procedure 76CP-9NP06, Revision 2, " Operating Procedure - Resin Drying Dewatering) System," contains instructions for the workers performing the resin fill head removal and capping of the HlC 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 filling the HIC 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 tne use of a torque wrench, which is required for final closure, to determine if the minimum torque required was achieved.

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i d. Procedure 75RP-0RP03, Revision 3.00, "ALARA Program," Section 2.15

-( provides in part that Work Group Supervisors are required to supervise j k jobs "to ensure that maximum benefit is derived from necessary. worker  !

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).

Contrary to the above, on December 15-21, 1992, the supervisor 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 to supervise during the actual job performance.

- This is a Severity Level 111 problem (Supplement IV).

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1 ENCLOSURE 2 REPLY TO NOTICE OF VIOLATION (EA 93-039)

NRC INSPECTION CONDUCTED JANUARY 11,1993 THROUGH FEBRUARY 12,1993 NRC INSPECTION REPORT 50-528/529/530/93-03 4

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REPLY TO VIOLATION A (50-528/93-03-05)

Admission 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 ,

overexposure was that Radiation Protection Support Services (RPSS) Depadment-activities were not always controlled with the same diligence, by Radiation Protection (RP)

Management, as Operations and Maintenance activities were controlled. The investigation C evaluated the barriers that should have prevented the radiation exposure in excess of the P

limits 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

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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 NRC-4 when notified that it was ready to be signed.

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' Corrective Steps That Have Been Taken And Results Achieved Enclosure 3 provides detailed corrective actions, including appropriate management- ,

controls, which have been taken to correct the identified causes of the issues surrounding 1

this incident.

In addition to the worker, the worker's supervisor is now notified when a worker's Form NRC-4 is 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 ensure that the quarterly dose limit of one and one quarter rems, without a completed Form NRC-4, will not be exceeded.

9 Corrective Steps That Will Be Taken To Avoid Further Violations The actions described above should prevent further violations of this type.

Date When Full Compliance Will Be Achieved Full compliance was achieved on December 21,1992, when the individual signed his Form NRC-4 k  ;

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REPLY TO VIOLATION B (50-528/93-03-03)-  ;

( i Admission Or Denial Of The Alleaed Violation APS admits the violation.

Reason For The Violation 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.

Corrective Steps That Have Been Taken And Results Achieved.

REP pre-job planning procedures have been revised to define review requirements. RP Technicians b' een briefed on this event. Interviews of RP personnel by APS OA and -

RP managemen, .iave determined that these briefings were effective. Appropriate disciplinary action was administered to the REP preparer.

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, .c Corrective Steps That Will Be Taken To Avoid Further Violations

. i The development of model REPS, similar to those being used for refueling outage activities, will provide additional guidance for evaluating survey data and. performing

.i surveys during the performance of work activities.

Date When Full Compliance Will Be Achieved Full compliance was achieved on December 21,1992, at the conclusion of the work when.

the survey was no longer required.

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REPLY TO VIOLATION C (50-528/93-03-04) )

- Admission Or Denial Of The Alleaed Violation l 1

APS admits the violation.

Reason For The Violation 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 preparer and RP Technician covering the job not being fully aware of the job scope and the need for head and upper arm dosimetry.

Corrective Steps That Have Been Taken And Results Achieved 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 Supervisor involvement in pre-job briefings. Appropriate disciplinary action was administered to the REP preparer and RP Technician.

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CorrectNe Steps That Will Be Taken To Avoid Further Violations I(

The development of model REPS, similar to those being used for refueling outage

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activities, will provide additional guidance for evaluating survey data and work scope to l determine dosimetry location requirements. '

Date When Full Compliance Will Be Achieved Full compliance was achieved on December 21,1992, at the conclusion of the work when the personnel dosimetry requirements were no longer required.

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REPLY TO VIOLATION D (50-528/93-03-02)

. Admission Or Denial Of The Alleaed Violation APS admits the violation.

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 this incident determined that 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 controlled. 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 controlling 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 e number of contributing causes for the failure to follow procedures. These included: 1) lack of sensitivity to short high dose rate jobs; 2) lack of a questioning attitude; 3) lack of planner involvement in field k '

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activities ^; 4) overconfidence due to familiarity with work; 5) lack of supervisor involvement; -

and 6) unclear management expectations for RPSS activities.

Corrective Steps That Have Been Taken And Results Achieved 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 Supervisor involvement in pre-job briefings. These corrective actions include an emphasis on personal accountability and procedure compliance.

i Corrective Steps That Will Be Taken To Avoid Further Violations C

APS believes that the corrective actions discussed above should prevent further violations of this type. .

I Date When Full Cmpliance Will Be Achieved For example 1, fu!! compliance was achieved on May 24,1993, when the ALARA review for the change from a Enviralloy HIC to a polyethylene HIC 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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l Addition'al Information Example 9 identified a procedure violation where the worker " . installed the HIC lid by hand without the use of a torque wrench, which is required for final closure, to determine if the minimum torque required was achieved." APS does not torque the HIC lid immediately following installation. Once the HIC lid has been torqued it is difficult to remove. Since the HIC lid may have to be removed to allow for sampling of the HIC-contents, the HIC lid is normally torqued (final closure) during final preparation for shipping the HIC. The procedure sign-off checklist is left open until the torquing is l

completed and verified. Therefore, the worker did not, nor was he expected to, torque the HIC lid for final closure during the resin fill head removal and capping of the HIC.

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ENCLOSURE 3

( RESULTS OF APS' INTERNAL INVESTIGATION

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RESULTS OF APS' INTERNAL INVESTIGATION 1

An APS Incident investigation Team (ilT) conducted an integrated investigation of the performance 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 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 limits 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 ALARA planning organization; 4) revised REP and ALARA pre-job planning procedures to define signature and review requirements; and 5) clarification of the requirements for RP Senior Technician and RP Supervisor ~ involvement in pre-job 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 (exoected to be completed by July 31,1993); 5) incorporating the significance of body positioning and reliance on alarming dosimeters into continuing training for RP personnel (expected to be completed by June 1,1993); and 6) briefing RP personnel on this incident.

APS Quality Assurance (QA) 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 QA has identified weaknesses 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 1 of 2

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a each case, RP Management has made improvements to the corrective actions to eliminate the weaknesses APS OA identified (procedures were revised to clarify

.b requirements and RP Management provided guidance to eliminate potential problems and weaknesses). APS OA follow up to the improvements to the corrective actions concluded -

that the improvements were effective.

APS OA also interviewed the personnel involved in this incident and verified that they a understood the personnel errors that contributed to this incident. Additionally, APS OA Q conducted independent interviews of RP personnel and verified that the briefings on this 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 Programmat,ic (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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