ML20082J325
| ML20082J325 | |
| Person / Time | |
|---|---|
| Site: | Peach Bottom  |
| Issue date: | 04/11/1995 |
| From: | Rainey G PECO ENERGY CO., (FORMERLY PHILADELPHIA ELECTRIC |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| NUDOCS 9504180212 | |
| Download: ML20082J325 (9) | |
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PECO ENERGY T,N"T "**"'
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Delta PA 17314-9739 717 456 7014 '
LApril 11,!1995; Docket'No. 50-277
~ License No. OPR44 i
U. S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, DC 20555
Subject:
Peach Bottom Atomic Power. Station Units 2 & 3 Response to Notice of Violation (Combined Inspection Report No. 50-277.-
& 50-278/95-05) i
- Gentlemen:
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in response to your letter dated March 14, 1995, which transmitted the Notice of Violation concerning the referenced inspection report, we submit the attached response, i
The subject report concerned a reactive radiological controls inspection that was conducted February 6-9,1995.
!f you have any questions or desire additional information, do not hesitate to contact us.
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Gerald R. Rai y Vice President j
Peach Bottom Atomic Power Station Attachment i.
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R. A. Burricelli, Public Service Electric & Gas R. R. Janati, Commonwealth of Pennsylania T. T. Martin, US NRC, Administrator, Region I W. L. Schmidt, US NRC, Senior Resident inspector j
. H. C. Schwemm, VP - Atlantic Electric R. l. McLean, State of Maryland A. F. Kirby lli, DelMarVa Power 1 CCGSEJ 4h CCN 95-14034 95o4180212 950411 PDR ADDCK 05000277 l}l Q
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RESPONSE TO NOTICE OF VIOLATION Restatement of Violation Technical Specification.(TS) 6.13.1 states, in part, "In it;u of the " control device" or
" alarm signal" required by paragraph 20.203(c)(2) of 10 CFR 20, entrance into a HRA sha!! be controlled by issuance of a Radiation Work Permit. Any individual or group of indiviouais permitted to enter such areas shall be provided with or accompanied by one or more of the following.
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A radiation monitoring device which continuously indicates the radiation dose rate in the area.
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- A radiation monitoring device which continuously integrates the radiation dose rate in the area and ahrms when a preset integrated dose is received. Entry into such areas with this monitoring device may be made after the dose rate levels in the area have been established and personnel have been made knowledgeable of them.
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An individual qualified in radiation protection procedures who is equipped with a radiation dose rate monitoring device. This individual shall be responsible for providing positive control over activities within the area and shall perform periodic radiation surveillance at the frequency specified by the plant health physicist or his designee on the Radiation Work Permit."
Contrary to the above:
On October 10,1994, four individuals entered the Unit 2 offgas pipe tunnel high radiation area (HRA), which was visibly posted as a HRA, and the individuals were not provided j
with the required radiation monitoring device, nor was positive control provided by an individual qualified in radiation protection procedures, nor did the individuals adhere to posted instructions regarding entry requirements, a requirement of the Radiation Work Permit under which the entry was made.
On October 31,1994, a Senior Reactor Operator (SRO) entered the Unit 2 high pressure coolant injection (HPCI) turbine room, which was visibly posted as a HRA, and the individual was not provided with the required alarming dosimeter, nor positive control provided by an individual qualified in radiation protection procedures, nor did the i
individual adhere to posted instructions regarding entry requirements, a requirement of the Radiation Work Permit under which the entry was made.
These represent examples of a Severity Level IV violation (Supplement IV).
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l Backaround Example (1)
On October 8,1994, a Security Firewatch (SFW-1) identified that the monitor which viewed the fire barriers in the Unit 2 turbine off-gas pipe tunnel was inoperable. The Security Supervisor (SS-1) was notified who contacted the Fire Protection Supervisor (FPS-1) to determine the appropriate method to accomplish the required firewatch, in lieu of the visual monitor. The FPS-1 instructed SFW-1, SS-1 and SS-2 (the night Security Supervisor) of the method to be employed to accomplish the required firewatch which did not in_volve entry into the Unit 2 turbine off-gas pipe tunnel. After the firewatch was -
established, SS-1 notified the Operations Shift Supervisor (OSS-1) of the' discovery.
Since the firewatch had been established and the equipment was scheduled for repair, OSS-1 did not make an additional entry to update the log which originally required that the Unit 2 turbine off-gas pipe tunnel fire barriers be monitored.
The firewatch was successfully accomplished between shifts as previously instructed by -
FPS-1 until the day shift on October 10,1994. During the Secunty turnover on that day, the new oncoming crew was not made aware that the Unit 2 Turbira off-gas monitor was
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inoperable. Subsequently, the day shift Security Firewatch (SFW-R identified that the monitor was out of service and reported this to his Security Supervisor (SS-3). Since the firewatch rounds turnover was conducted between firewatch crew members and did not include Security supervision, SS-3 was not aware that the monitor had previously been identified as inoperable. SS-3 contacted the Operations Shift Supervisor (OSS-2) to inform him of the inoperable monitor and to determine if a firewatch would be required.
OSS-2 was also unaware that the monitor had previously been identified as inoperable.
l OSS-2 determined that a firewatch was required and Security was instructed to set up l
firewatch rounds. OSS-2 contacted Fire Protection technicians (FPT-1 and FPT-2) to l
investigate the out of service monitor. The FPTs were aware that the area being monitored was contaminated, so they contacted Health Physics (HP) to obtain a briefing on the radiological conditions of the area. At the control point entrance to the area,'a HP ~
technician (HPT-1) provided a briefing to the two FPTs.- HPT-1 relied on his previous knosvledge of the area and failed to talk about the high radiation area (HRA) which was clearly listed on the most recent survey data available._ HPT-1 failed to identify this hazard and the proper entry requirements of a HRA to the FPTs.
The FPTs proceeded to enter the area after obtaining the prescra:d personnel contamination clothing. Upon entering the Unit 2 off-gas pipe tunnel the FPTs observed a HRA posting. Both individuals assumed the posting was incorrect and proceeded past the boundary since there was no mention of any HRAs during the HP briefing. FPT-1 then notified SS-3 that they would perform the first firewatch round since they were in the area to investigate the monitor inoperability. Security then began to set up to perform subsequent firewatch rounds.
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l' The,first scheduled Security Firewatch (SFW-2) was instructed to contact FPT-2, by name only, to obtain the necessary information about the fire watch and the situation.
SFW-2 contacted FPT-2 and questioned him about the dress-out requirements for entering the area because he believed that FPT-2 was a HP technician. Before SFW-2 was prepared to perform the firewatch, however, he was called away to perform Emergency Medical Technician duties. Another Security Firewatch (SFW-3) was then contacted to perform the required firewatch.
FPT-2 was still in the area when SFW-3 arrived. FPT-2 informed SFW-3 of the dress-out requirements that he had been previously given during the HP briefing. SFW-3 questioned why digidoses were on the step-off pad, but FPT-2 responded that there was no dose in the area. SFW-3 also assumed FPT-2 was a HP technician and proceeded to dress-out and then enter the HRA to perform the firewatch duties.
During the next firewatch rounds, SFW-2' returned to the area. Since he had previous discussions regarding the dress-out requirements with an individual he thought was a HP technician, he proceeded to dress-out and then enter the HRA to perform the scheduled firewatch. Later that same day, prior to entering the HRA, SFW-2 was stopped by a HP technician (HPT-2) who was in the area overseeing another job. HPT-2 questioned SFW-2 with respect to dosimetry and what job task he was assigned. SFW-2 responded he was performing a firewatch round and was reqinred to go to the back of the pipe tunnel. HPT-2 informed him that he would be entering a HRA and that entry into a HRA required a digidose. SFW-2 responded that he had pmviously entered the area four or five times without a digidose. HPT-2 requested that SFW-2 exit the area with him to discuss this matter with HP supervision.
Backaround Example (2)
On October 31,1994, a Senior Reactor Operator (SRO) was assisting a Nuclear Plant Operator (NPO-1) with an instrumentation problem at the main turbine lube oil reservoir.
Approximately ten minutes later. an urgent message was transmitted over NPO-1's radio from the Control Room Superviror (CRS) that smoke was reported in the Unit 2 HPCI room by a Nuclear Plant Operater (NPO-2) who was at the location. The SRO received the message and responded to the Unit 2 HPCI room.
Upon arrival at the Unit 2 HPCI room entrance, the SRO did not notice an insert in the radiation area posting indicating the room was a HRA. Entrance ways to the HPCI room are considered HRA barriers when the system is in operation. The HPCI system had been placed in operation to provide data in support of the Unit 2 re-rate testing. Due to the infrequent operation of the HPCI system, upgraded postings and a rope barrier inside the HPCI door are expected to be in place to help prevent inadvertent access during operation. The SRO paused approximately 20 seconds at the HPCI door, with the door open, surveying the room for any personnel in the area. A significant amount of smoke was encountered at this time in the room. An administrative rope barrier, normally hung across the doorway to prevent access during HPCI operation, was not in place.
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The,SRO entered the room and began to observe conditions in the room as he traversed clockwise arour.d the HPCI turbine toward the Reactor Core Isolation Cooling (RCIC) room watsttight door. The SRO opened the door and found a rope barrier across the doorway, and a Health Physics (HP) technician and NPO-2 standing on the other side.
The HP technician. questioned the SRO about his presence in the room and if he had an alarming dosimeter. The HP technician and the SRO then moved to a low dose area where the HP technician provided a briefing on current radiological conditions in the room and provided an alarming dosimeter to him. The HP technician notified HP j
supervision of the event and a HP supervisor was dispatched to investigate the incident.
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Reasons For the Violation (Exa'mple 1)
The communication between Fire Protection personnel was less than adequate. The Fire Protection personnel involved in the incident on October 10,1994, had no knowledge the impairment had been previously identified and that the Fire Protection Supervisor had set up a firewatch method on October 8,1994, which did not involve entry into the Unit 2 off-gas pipe tunnel. Additionally, the firewatch instructions determined by the Fire Protection Supervisor had not been documented or communicated to these individuals.
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The Security turnover on October 10,1994, was less than adequate. The details of the
.firewatch rounds and notification of the monitor inoperability should have been communicated to the on-coming shift. Day shift personnel were not made aware of the existing situation.
The pre-job briefing given by the HP technician was less than adequate. The briefing was given from memory and the most recent survey information was not utilized. The HP technician did not advise the Fire Protection personnel of the HRA and reinforce the HRA entrance requirements.
The Fire Protection personnel encountered a HRA posting, but failed to stop and question the discrepancy between the area briefing and the posting. They also failed to -
stop and obtain the correct dosimetry for the HRA. The Fire Protection personnel displayed a less than adequate questioning attitude when faced with recognized discrepancies.
The Security personnel assumed they were briefed by a HP technician, when they were actually talking to a Fire Protection technician. The Security Firewatches also noticed HRA postings, but thought they had HP permission to enter these areas without digidoses. Although one Security Firewatch questioned the use of digidoses prior to entering the area, the Fire Protection technician informed SFW-3 that a digidose was not necessary because there was no dose in the area.
(Example 2)
The radio communications between Operations personnel was inadequate. The initial radio transmission did not provide sufficient detail or a full explanation of the situation.
The SRO perceived the communication to be an emergency situation and failed to take appropriate precautions when he encountered the area.
The HRA barrier (a rope with a warning sign) was ineffective. The rope / sign barrier was originally attached across the door entrance by a self-sticning fastener. The adhesion -
capability of this device dissipates over time, allowing the rope and sign to drop off to the side, negating the effectiveness of the barrier.
Control of the barrier was inadequate. Responsibility for maintaining the physicalintegrity of the barrier was not clear.
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i The SRO did not recognize the change in the radiological posting on the Unit 2 HPCI door. The HPCI room is normally not a HRA, and the posting was one of six different signs on the door. The SRO concentrated his efforts on personnel safety and equipment status without fully evaluating the potential radiological or environmental conditions.
The Corrective Steos That Have Been Taken and the Results Achieved (Example 1)
Radiological access holds were placed on the individuals involved until HP management could interview the personnel to ensure they understood the entry requirements for HRAs.
A Performance Enhancement Program (PEP) issue was initiated October 10,1994, to determine causal factors of this event and to develop appropriate corrective actions to prevent recurrence.
Personnel involved were counselled about' prcper work methods and HRA entry requirements. Appropriate disciplinary actions were levied on the individuals involved.
General Employee Training (GET) programs were revised to stress the requirements for entry into HRAs. The appropriate revisions were completed November 16,1994.
i HP, Fire Protection and Security All-Hands meetings were conducted to review this incident with the appropriate personnel. Specific performance problems exhibited during the event were discussed.
The Unit 2 off-gas tunnel camera was repaired to allow continuous remote monitoring of the fire barriers.
The Station Vice President communicated the event by the ASPEN voice processing system to site supervision so that the information could be communicated to the respective work groups to raise awareness and to help prevent recurrence. In addition, HRA entry requirements and management expectations concerning HRAs was communicated to personnel by site wide publications.
A specific Security Firewatch logbook has been established to document non-routine l
required activities. This logbook is reviewed on each shift to ensure the continuity of firewatch activities between shifts.
An Industrial Risk Management (IRM) turnover logbook has been developed and l
implemented. A memorandum was issued to IRM personnel explaining the reason for initiating this process.
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i Methods to distinguish HP technicians from other workers in the plant were evaluated.
i As a,res' ult of this evaluation, it was determined that the use of HP identification badges l
would be utilized to differentiate HPs from the general plant population. Other measures 1
l may be evaluated during outages, when additional personnel are on site, to ensure HP l
technicians in the field are easily distinguishable from other personnel.
A list of HRAs was compiled and each HRA was evaluated. Action plans for each area were developed to either prevent inadvertent access into a HRA by the addition of physical barriers or to eliminate or reduce dose rates by flushing pipe or. adding j
shielding. Enhanced HRA postings have been developed that are more human factored.
The postings clearly specify the requirements to obtain an electronic dosimeter, HP i
briefing and RWP prior to entry. These postings have been located at HRAs where access can not be controlled by locking the area. This corrective action pertains to both j
examples.
(Example 2) l The HP technician provided a briefing to the SRO and provided him with an alarming l
dosimeter.
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A PEP issue was initiated October 31,1994, to determine causal factors of this event
[i and to develop appropriate corrective actions to prevent recurrence.
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The individual involved was counselled about the event and appropriate disciplinary actions were levied.
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Interim corrective action was to relocate the rope and sign to_the bottom of the southwest staircase. This allows the rope, with clasps attached, to be clipped around the i
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handrail to form a barrier that will not fall and makes the sign obvious to personnel.
j Additional radiological postings for the HPCI & RCIC rooms-were evaluated and implemented November 11,1994. HP Job performance standards for HPCI and RCIC l
have also been implemented that provide expectations and guidance concerning the radiological posting and posting removal requirements, and control of radiological j
barriers.
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Issuance of alarming dosimeters to Operations personnel was evaluated and j
implemented by the HP department on January 31,1995. Operations personnel are still j
required to obtain a pre-job briefing and fulfill RWP requirements prior to entering any -
HRA.
Effective three part communication continues to be stressed in daily operation activities through performance indicators and coaching. Clear and effective communication is also continually evaluated during simulator activities. Communications is an area that is constantly being assessed for improvement.
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The _ Corrective Steos that Will Be Taken to Avoid Further Violations l
The corrective steps that have been initiated as a result of this event will serve to avoid further violations.
A summary of these events will be included in required reading for Operations personnel i
with an emphasis on complete logkeeping, effective communication, and high radiation l
area entry requirements. This will be completed by June 25,1995.
HP notification response cards are also under development which will direct HP personnel to evaluate the radiological conditions of an area or system when notified by Operations of a change in system status. The response cards will direct HP personnel on the appropriate actions to be taken, including proper posting and area control. These standards and cards will be developed and implemented by December 31,1995.
i Date When Full Compliance Was Achieved Full compliance was achieved October 10,1994, when personnel exited the Unit 2 off-gas pipe tunnel and on October 31,1994, when the SRO exited the Unit 2 HPCI room, resulting in a restoration of the high radiation area boundaries.
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