ML20059A340

Responds to Violations Noted in Insp Rept 50-293/93-16. Corrective Actions:Work in Progress Stopped,Individuals Sent for Whole Body Count,Survey of Affected Areas Completed & Workers Restricted from RCA Pending Review

ML20059A340
Person / Time
Site:	Pilgrim
Issue date:	12/24/1993
From:	Boulette E BOSTON EDISON CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
93-158, NUDOCS 9312300112
Download: ML20059A340 (5)

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j6I 10 CFR 2.201 BOSTON EDISON Pilgrim Nuclear Power Station Rocky Hall Road Plymouth. Massachusetts 0236o E. T. Boulette, PhD Senior Vice President - Nuclear December 24 , 1993 BECo Ltr. #93 158 U.S. Nuclear Regulatory Commission Attention: Document Control Desk Washington, DC 20555 License No. DPR-35 Docket No. 50-293

Subject:

REPLY TO NOTICE OF VIOLATION

Reference:

NRC Region 1 Inspection Report 50-293/93-16 Enclosed is Pilgrim Station's reply to the Notice of Violation contained in the referenced inspection report.

We acknowledge the weaknesses that have been identified in our Radiation Protection (RP) Program and have taken corrective actions to remediate these concerns and prevent their recurrence. Pilgrim Station is committed to maintaining a strong RP program and will continue to make additional improvements in the ensuing months. We believe the self assessment program that identified these weaknesses is an effective process and integral to our continued success.

We appreciate your acknowledgment of the overall good performance of the radiological controls program. While we do believe that individual accountability is fundamental to radiation protection and will continue to emphasize this at the station, other proactive efforts, including specific changes to the RP Program are also taken when warranted. With regard to the subject violation, your inspection report stated that there was no comprehensive corrective action commitment rade by our staff by the end of the inspection that addressed the failure to survey. As a matter of fact, prompt and effective corrective actions were taken within days of the incident. The root cause of the specific incident was determined to be human error by contractor technicians. Immediate actions included:

+ immediately stopped work in progress e individuals were sent for whole body count

. a survey of the affected area was completed

• the workers ' involved in the incident were restricted from the RCA pending an initial event review t:

9312300112 931224 l (t

goa noocnosoog3 t; f, ,

• the RP technicians and supervisors were counselled on the event f

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• the Earmark constant communications system was expanded to include the i

' night shift j A problem report was initiated in April to document the' immediate corrective actions, trigger a root cause analysis and determine the need for additional i preventive actions. In addition to counselling of the RP technicians and I supervisors, details of the event were incorporated into the radiological continuing -  !

training program. As such, details of the event will be presented to other RP i personnel as part of the on-going training. As of May 1993, the only outstanding preventive action associated with this event involved a commitment to conduct  !

advanced health physics training for contractor personnel. This training is .;

scheduled to be conducted prior to our next outage. The corresponding problem  ;

report will remain open until this training is complete. The measures taken in -  !

response to this event, along with a more aggressive health physics work force will i improve the radiological controls at Pilgrim Station. Additional details are j contained in the enclosed reply.  ;

We are concerned with the lack of communication that existed during the on-site l portion of the inspection. There was no indication throughout the inspection that '

any potential violations had been identified. We would have appreciated the  ;

opportunity to discuss the details of this violation prior to issuance. We are interested in pursuing this matter further in order to improve communications during i future inspections.

Please do not hesitate to contact me if there are any questions regarding this  ;

concern.  !

E v boaL2R

/.

E. T. Boulette, PhD i

4 GJB/bal Enclosure .

cc: Mr. Thomas T. Martin i Regional Administrator, Region I  !

U.S. Nuclear Regulatory Commission l 475 Allendale Road 1 King of Prussia, PA 19406 ,

1 Mr. R. B. Eaton i Div. of Reactor Projects I/II  :

Office of NRR - USNRC .

One White Flint North - Mail Stop 14D1  !

11555 Rockville Pike Rockville, MD 20852 l Senior Resident Inspector i

ENCLOSURE REPLY TO NOTICE OF VIOLATION 50-293/93-16-05 Boston (dison Company Docket No. 50-293 l Pilgrim Nuclear Power Station License No. DPR-35 As a result of an inspection conducted on August 30 through October 15, 1993, the following violations of NRC requirements were identified. In accordance with the NRC <

Enforcement Policy (10 CFR 2, Appendix C), the violation is licted below.

10 CFR 20.201, " Surveys", requires that "each licensee shall make or cause to be i mule such surveys [ evaluations of the radiation hazards incident to the production, '

use, release, disposal or presence of radioactive materials] as (1) may be necessary for the licensee to comply with the regulations in this part, and (2) are reasonable under the circumstances to evaluate the extent of radiation hazards that may be -

present" Contrary to the above, on April 30, 1993, an inadequate evaluation of radiation  ;

hazards associated with main steam line plugs was made, resulting in three workers sustaining unplanned internal radiation exposures. Specifically, the individuals worked on main steam line plugs that had not been surveyed, butp which were later determined to exhibit contamination levels of 5 mrad /hr/100 cm smearable and a total contamination level of 30 mrem /hr measured at contact with the plugs.

This is a Severity Level IV violation. (Supplement VI)

REASON FOR VIOLATION t

. i The inadequate evaluation of the radiation hazards associated with work on the main steam line plugs was caused by contractor personnel error. The Radiation Protection - (RP) technicians responsible for the work being performed failed to conduct a survey of the area and as a result did not stipulate additional radiological controls (i.e., face shields, respirators, etc.) on the Radiation Work Permit (RWP). Inadequate communications between the RP technicians and individuals performing the work contributed to the event.

The two RP technicians and three workers on the job were contractor personnel employed by A.B.B., Incorporated.

The three workers who were tasked for the job were properly signed in on the correct RWP and dressed in appropriate protective clothing as specified by the RWP. Prior to performing the work, the workers discussed the job with the RP technician at the Control Check Point on the 91' elevation of the Reactor Building. The RP technician advised the workers to contact the roving RP technician on the refuel floor of the Reactor Building elevation 117', where the job was to be conducted. The roving technician would then i assess the radiological conditions associated with the main steam line plugs and determine  :

if additional controls were needed. While it is unclear if the workers contacted the  ;

roving RP technician, the main steam line plugs were not surveyed prior to the start of )

the job. i It appears that there was al so a lack of communication between the RP technicians responsible for the two floors. The technician at the control check point did not contact the roving technician on the refuel floor to discuss the nature of the job. Not withstanding the apparent communications problem associated with this work activity, the roving RP technician still failed to take appropriate action even after becoming aware of i

the work being performed. He did not recognize that a survey had not been performed to establish the contamination levels associated with the steam plugs and related components.

After observing the workers packaging the steam plugs and realizing that additional protection may be needed, the technician attempted to locate face shields but was unsuccessful. Work was allowed to continue with no survey of the area and no additional protection for the workers.

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.. 1 Procedure 1.3.106, '" Conduct of Radiological Operations", requires that prejob briefings be i conducted between RP personnel and individuals tasked with a job. The purpose of the  ;

briefings is, to' discuss the radiological conditions associated with the work to be performed. While these briefings were conducted for the ongoing work, they were general  ;

in nature and did not provide sufficient detail at the job location where the specific  ;

radiological conditions needed to be assessed and reviewed. ,

It was determined that at the time gf the incident, a dose rate of 30 mrem / hour and a .

contamination level of 5 mrad /100 cm existed at contact with the main steam line plugs. i

- Air lines (hoses) connected to the steam plugs also contributed to the high levels of  !

contamination. The dose rate at pthe hoses was approximately 20 mrem / hour; the highest ,

smear recorded was 30 mrad /100 cm .

CORRECTIVE ACTIONS TAKEN AND RESULTS ACHIEVED Upon change of the radiological work shift, the new RP technician assigned to the refuel f floor immediately stopped the work in progress and surveyed the area. Smears were taken  ;

of the yet to be packaged steam plugs and other related equipment. Examination of the .

,- individuals including whole body counts, revealed slight facial contamination and evidence i l of internal radiation exposure. Precautions were taken, including the use of facemasks,  !

to complete the job with no additional radiological problems encountered.

, The personnel involved with the job including RP supervisors, technicians and individuals  ;

performing the work were counselled by management. The counselling given to the RP personnel focused on the importance of providing aggressive coverage to ensure proper ,

radiological controls Good communications was also stressed as an essential ingredient  !

to effectively control radiological conditions. The three individuals performing the work j were also counselled. The importance of open and thorough communication with RP r technicians was stressed. Recognizing the need for additional radiological guidance for  ;

various jobs and more accountability for one's own dose were also discussed. l I

As a result of the event, better RP personnel communications were established. The use of l radio headphones was implemented to enable constant communication among technicians and  !

! this practice continued for the remainder of the refuel outage. The effectiveness of communications and RP coverage improved significantly.

CORRECTIVE ACTION TAKEN TO PREVENT RECURRENCE l

The continuing training program given to radiation protection technicians was revised to )

incorporate details of this event into the industry events module. The training will focus on the need for technicians to provide aggressive radiological protection coverage and the importance of clear and thorough communications during all jobs. This training will be given prior to the next outage scheduled for October of 1994 (midcycle outage no.

10).

The use of radio headphones is planned for future outages. The radiation protection outage checklist was revised to ensure proper communications are established in areas 'of high work activity (e.g., Drywell, Refuel Floor, etc.).

Radiation worker training will continue to promote individual responsibility and accountability. The training will stress the importance of good communications between workers and RP personnel in order to minimize radiological hazards and maintain exposures ALARA. In addition, a radiation awareness program exists, providing another source of radiological information to plant personnel. Also, the health physics training program will promote more aggressive radiological coverage thereby contributing to the enhancement of Pilgrim Station's radiation protection program.

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-'DATE OF FULL COMPLIANCE I t- . The continuing training program was revised in December of 1993. Training of appropriate-personnel in61uding contractors will be conducted prior to our. October 1994 mid-cycle' ]

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