ML20132G615

Forwards Insp Rept 50-213/96-12 on 961102-27.Apparent Violations Being Considered for Escalated Enforcement Action IAW, General Statement & Proceddure for NRC Eas, NUREG-1600

ML20132G615
Person / Time
Site:	Haddam Neck File:Connecticut Yankee Atomic Power Co icon.png
Issue date:	12/19/1996
From:	Wiggins J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Feigenbaum T, Harpster T NORTHEAST UTILITIES SERVICE CO.
Shared Package
ML20132G620	List: ML20132G615 ML20132G621
References
RTR-NUREG-1600 EA-96-496, NUDOCS 9612260316
Download: ML20132G615 (10)

See also: IR 05000213/1996012

Text

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December 19, 1996

EA 96-496

Mr. Ted C. Feigenbaum

Executive Vice President and Chief Nuclear Officer

Northeast Utilities Service Company

c/o Mr. Terry L. Harpster

P.O. Box 270

Hartford, CT 06141-0270

SUBJECT: NRC INSPECTION REPORT 50-213/96-12

Dear Mr. Feigenbaum: l

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A special reactive safety inspection was conducted by personnel from the NRC Region l l

Office during the period November 2-27,1996, at the Haddam Neck Power Station,

Haddam, Connecticut. The purpose of the inspection was to review the circumstances,

licensee evaluations, and corrective action associated with an airborne radioactive material

event that occurred in the fuel transfer canal and reactor cavity on November 2,1996. As

part of this review, the Senior Resident inspector evaluated your staff's response to delays

in the resumption of core offload preparations associated with the event. A preliminary I

summary of the inspection results was provided by Messrs. W. Raymond and R. Nimitz, of

this office, to Mr. G. Bouchard and others of your organization on November 8,1996, and i

to Mr. J. Hasettine, also of your organization, on November 22,1996. Additionally, l

Messrs. Raymond, White and Nimitz of our office informed Mr. J. LaPlatney of your staff  ;

of our preliminary assessment in a telephone discussion on November 27,1996.

The NRC inspection identified significant deficiencies in the oversight and control of i

licensed activities, including programmatic breakdown in radiological controls and poor

work planning, control, and practices relative to defueling activities on November 2,1996.

As a result, personnel were exposed to high concentrations of airborne radioactive material

and handled highly radioactive debris, resulting in a substantial potential for an

occupational exposure in excess of NRC regulatory limits. We are particularity concerned

about your organization's failure to: (1) adhere to fundamental radiological safety

requirements (such as effective communication and understanding of work scope,

knowledge of actual radiological conditions and potential safety consequence, and conduct

of appropriate radiological surveys or evaluations); (2) recognize the potential health and

safety consequence of the emergent situation and respond appropriately; and (3) recognize

and effectively communicate to management, a situation which delayed defueling activities

and resulted in maintaining the reactor in a heightened shutdown risk condition for an

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9612260316 961219

PDR ADOCK 05000213 I" LN> h I

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Mr. Ted C. Feigenbaum 2

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extended period. Further, we are concerned that your staff failed to recognize that a

1 substantial potential existed for personnel exposure to airborne radioactivity containing

alpha emitters and consequently failed to initiate timely and appropriate personnel exposure

evaluation.

Based on the results of this inspection, five apparent violations, some with multiple

examples of non-compliance, were identified. These include failure to implement corrective

actions for conditions adverse to quality, failure to adequately instruct workers in

precautions and procedures to minimize exposures, failure to perform adequate radiological

surveys to characterize and evaluate radiological conditions and potential personnel

exposures, failure to adhere to Technical Specification High Radiation Area control

requirements, and failure to adhere to radiation protection procedures. These apparent

violations are summarized in Enclosure 1 to this letter and are further detailed in the

inspection report, Enclosure 2. These violations are being considered for escalated

enforcement action in accordance with the " General Statement of Policy and Procedure for

NRC Enforcement Actions" (Enforcement Policy), NUREG-1600.

As discussed in a telephone conversation on December 16,1996, between you and

Mr. Rogge of this office, the circumstances surrounding these apparent violations are well

understood by our staff. We believe that the root causes of these latest deficiencies are

similar in nature to the weaknesses in conduct of operations, corrective action

effectiveness, and management oversight and control that led to the previously identified

apparent violations that were discussed in the Predecisional Enforcement Conference on  :

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December 4,1996. At that conference, you acknowledged that the findings relative to

this unplanned exposure event reflected the same global issues that were apparent in the

previous performance deficiencies. Further, we reviewed and evaluated your interim short

terrn corrective actions as described in your letter dated December 9,1996; the results of

your " Independent Review Team on the November 2,1996 Radiological incident and

Reactor Disassembly Delay at the Haddam Neck Plant," dated December 5,1996; and your

assessment as reported in Licensee Event Report No. 50-213/96-030-00, dated

December 6,1996. Accordingly, we believe that we have sufficient understanding and

information to enable our staff to make an enforcement decision. Based on the telephone  ;

discussion with Mr. Rogge, we understand that you do not require a predecisional

enforcement conference for these matters. Notwithstanding, we are concerned about the

adequacy and effectiveness of your corrective actions as they relate to your staff's ability

to safely progress with decommissioning activities. Consequently, we plan to meet with

your organization in early February to discuss corrective actions taken or planned, and

planned staffing and activities relative to the future decommissioning of the Haddam Neck

Plant. If our understanding is incorrect, please notify Mr. John Rogge, of our office, within

7 days, at 610-337-5146.

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Mr. Ted C. Feigenbaum 3

{ A Notice of Violation is not presently being issued for these inspection findings, '

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consequently no response to this letter is required. You will be advised by separate

correspondence of the results of our deliberations in this matter. The number and

characterization of apparent violations describe in the enclosed report may change as the

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result of further NRC review. In accordance with 10 CFR 2.790 of the NRC's " Rules of

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Practice," a copy of this letter and enclosures will be placed in the NRC Public Document

Room (PDR). l

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Sincerely,

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0@ina(&nd$y:  !

knu'E Ssiggins

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. L manso ess.

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, James T. Wiggins, Director ]

2 Division of Reactor Safety .

] I

Docket No. 50-213

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Enclosures:

) 1. Executive Summary and List of NRC Concerns and Apparent Violations l

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2. NRC Inspection Report No. 50-213/96-12

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cc w/encts:

B. D. Kenyon, President and Chief Executive Officer - Nuclear Group

D. Goebel, Vice President - Nuclear Oversight l

J. Thayer, Vice President - Nuclear Engineering and Support Recovery Office

F. C. Rothen, Vice President - Work Services

i J. J. LaPlatney, Haddam Neck Unit Director

L. M. Cuoco, Senior Nuclear Counsel l

J. E. Van Noordenen, Licensing Manager - Haddam Neck

H. F. Haynes, Director - Training

J. F. Smith, Manager, Operator Training

W. D. Meinert, Nuclear Engineer

State of Connecticut SLO

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Mr. Ted C. Feigenbaum 4

Distribution w/ enc!s:

Region 1 Docket Room (with concurrences)

D. Screnci, PAO

J. Rogge, DRP

i NRC Resident inspector

M. Conner, DRP '

C. O'Daniell, DRP

4

J. White, DRS

R. Nimitz, DRS

J. Wiggins, DRS

D. Holody, Enforcement Coordinator, RI

D. Chawaga, SLO

Nuclear Safety Information Center (NSIC)

PUBLIC

l DRS File

, Distribution w/encls (VIA E-MAIL):

J. Liberman, OE

F. Davis, OGC

l

F. Miraglia, NRR

R. Zimmerman, NRR

Enforcement Coordinators

RI, Ril, Rlli, RIV

W. Dean, OEDO

P. McKee, NRR/PD l-4

S. Dembek, PM, NRR

R. Jones, NRR

R. Correia, NRR (RPC)

R. Frahm, Jr., NRR (RKF)

Inspection Program Branch, NRR (IPAS)

M. Callahan, OCA

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DOCUMENT NAME: G:\RSB\NIMITZ\HN961 .I S

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NAME RNimitz 4 crJ WRa,vakfrW ' JRogge4)L(o J#9igV " JWigginsl V

DATE 12/18/96 12//[/796 12/pf/96 v'12fF /96 12/ M /9S

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OFFICIAL ret 0RD COPY

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ENCLOSURE 1

EXECUTIVE SUMMARY

Haddam Neck Station

NRC Inspection Report No. 50-213/96-12

Backaround

This inspection was a special reactive safety inspection to review an airborne radioactivity

event that occurred in the fuel transfer canal and reactor cavity at the Haddam Neck Plant

on November 2,1996. The inspection included aspects of licensee operations,

maintenance, and plant support, and the licensee's recovery from a significant radiological

event. The report covers the period November 2-27,1996.

Plant Operations:

Operators and plant staff showeo poor sensitivity to the control of shutdown risk during

the November 2,1996, reactor cavity / fuel transfer canal airborne radioactivity event. For

approximately 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br />, control room operators were not sensitive to the significant delay

in being able to complete work in the reactor cavity to support reactor cavity flood up.

Control room personnel did not exhibit questioning attitudes or seek to ameliorate the

conditions or circumstances even though the reactor was in an elevated risk state.

Maintenance:

Maintenance support for monitoring and tracking outage delays was poor and maintenance

personnel did not effectively track and evaluate delays in the outage activities that affected

shutdown risk potential. Further, these conditions were adverse to quality, and there was

no effective management control of outage delay that could affect shutdown risk potential.

These deficiencies resulted in the reactor remaining in a state of elevated risk, relative to

other shutdown conditions, on November 2 and 3,1996, for about an additional fifteen

hours. These performance deficiencies were considered adverse to quality, were not

identified, and were not corrected until pointed out by an NRC inspector. This is

considered a significant lack of attention to safety. In addition, these observations were

considered an apparent violation of 10 CFR Part 50, Appendix B, Criterion XVI. i

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Plant Support:

Plant management and staff failed to effectively plan and control radiological work i

activities (inspection of the fuel transfer system in the transfer canal) on

November 2,1996. As a result, personnel were exposed to high concentrations of

airborne radioactive material and handled highly radioactive debris resulting in a substantial

potential for an occupational radiation exposure in excess of NRC limits. The event i

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revealed deficiencies in planning and control of outage work activities and ineffective

organizational communications. The licensee's staff failed to recognize that a potential

significant exposure of personnel to airborne alpha emitters may have occurred until it was

identified by an NRC inspector five days after the event. Quality Assurance and

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supervisory personnel did not detect program weaknesses in calibration and use of

equipment and air sampling. Further, recent organizational changes within the radiological

controls organization appeared to have adversely affected the overall effectiveness of the

organization.

A number of apparent violations of NRC requirements were identified including failure to

adequately instruct workers in precautions and procedures to minimize exposures, failure

to perform adequate radiological surveys to characterize and evaluate radiological

conditions and potential personnel exposures, failure to adhere to Technical Specification

High Radiation Area control requirements, and failure to adhere to radiation protection

procedures.

Safety Assessment & Quality Verification:

The plant management and staff failed to appreciate the significance of the delay in

resuming work activities in the reactor cavity to remove the reactor from its elevated risk

state. There were deficiencies in the quality of information and the integration of plant

resources and support activities to effec.tively respond to degraded plant conditions.

Apparent Violations:

1. Operations and Outaae Control

10 CFR 50, Appendix B, Criterion XVI (Corrective Action), requires in part, that

measures shall be established to assure that significant conditions adverse to quality

are promptly identified and corrected.

The inspector noted that from 10:00 a.m. November 2 until 1:00 a.m. on l

November 3, a contamination event inside the refueling cavity transfer canal  !

interrupted the reactor disassembly sequence for about 15 hours1.736111e-4 days <br />0.00417 hours <br />2.480159e-5 weeks <br />5.7075e-6 months <br /> at a time when the

reactor was in a condition of high shutdown risk, relative to other shutdown l

conditions, with water level drained to the refueling reference level (10 inches ,

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below the vessel flange). Licensee management controls of outage activities were

inadequate to 1) promptly identify significant delays in outage activities that could

impact the duration of the reactor in an elevated state of risk, and 2) were

inadequate to take prompt corrective actions to ameliorate conditions that affected

shutdown risk potential. The inadequacies in management control of outage

activities was considered a significant condition adverse to quality. This is an

apparent violation of 10 CFR 50, Appendix B, Criterion XVI. ,

2. Radioloaical Controls

a. The licensee did not make adequate radiological surveys, as required by 10 CFR

20.1501, as may be necessary to comply with the occupational exposure limits of

10 CFR 20.1201.10 CFR 20.1003 defines a survey as an evaluation of the e

radiological conditions and potential hazards incident to, among other matters, the .

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presence of radioactive material or other sources of radiation. When appropriate, f

such an evaluation includes a physical survey of the location of radioactive material  !

and measurements or calculations of levels of radiation or concentrations or  ;

quantities of radioactive material present. I

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Radiological surveys made in the reactor cavity and fuel transfer cavity, as

necessary to comply with the occupational exposure limits outlined in 10 CFR j

20.1201, were not adequate as follows

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1. On November 2,1996, two workers in the fuel transfer canal unknowingly  !

collected, handled, and transported radioactive material (debris) with contact  !

radiation levels ranging from 20 R/hr to 60 R/hr. The debris was not  :

surveyed as it was collected, handled or transported. Such surveys were

necessary and reasonable to ensure conformance with the occupational dose j

limits.

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2. On November 2,1996, airborne radioactivity surveys were not adequate to I

detect high concentrations of airborne radioactivity within the fuel transfer  ;

canal as workers collected highly radioactive dry dirt like debris therein.

Such surveys were reasonable in that areas traversed and worked in by the l

workers exhibited loose surface contamination levels measuring up to

80 mrad /hr (beta) contamination and up to 30,000 disintegrations per

minute /100 square centimeters alpha contamination (dpm/100 cm 2).

J. On November 2,1996, airborne radioactivity surveys were not adequate to

detect high concentrations of airborne radioactivity within the reactor cavity

to support reactor stud hole cleaning. As a result, two workers were

permitted to enter the reactor cavity notwithstanding the presence of high

levels of airborne radioactivity.

4. As of November 7,1996, the licensee had not effectively evaluated the

potential exposure of two workers, known to have been exposed to high

levels of airborne radioactivity, sufficient to make the determination that the

workers had substantial potential to exceed applicable regulatory limits

relative to intake of alpha emitting isotopes on November 2,1996.

b. 10 CFR 19.12(a) requires that s!! individuals who, in the course of their

employment, are likely to receive in a year an occupational dose of 100 mrem, be

kept informed of the storage, transfer, or use of radiation and/or radioactive

materials and be informed of precautions or procedures to minimize exposure.

1. On November 2,1996, two individuals entered the reactor cavity and fuel

transfer canal to perform inspections and housekeeping, received a dose in

excess of 100 mrem and the individuals were not adequately informed of the

presence of high levels of removable radioactive contamination and radiation

within the fuel transfer canal and were not adequately informed as to the

. precautions or procedures to minimize their occupational exposure.

Specifically, the workers were lead to believe that the fuel transfer canal was

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relatively clean as a result of its decontamination; the workers were not

informed of high levels of removable radioactive surface contamination (up to

about 80 mrad /hr (beta) and up to about 30,000 dpm/100 cm2 of removable

alpha radioactive contamination), and the workers were not informed of an

isolated hot spot on the floor of the transfer canal measuring up to 25 R/hr

on contact (about 8 R/hr at waist level).

2. On November 2,1996, as a result of inadequate radiological surveys, two

individuals, likely to receive 100 millirem in a year, entered the reactor cavity

at about 9:30 a.m. to perform stud hole cleaning of two stud holes on the

reactor and were not informed of high levels of airborne radioactivity within )

the reactor cavity. i

The above examples of failure to adequately inform the workers of the radiological

conditions within the fuel transfer canal and reactor cavity and of precautions or

procedures to minimize their exposure were an apparent violation of 10 CFR 19.12.

c. Technical Specification 6.11 requires that procedures for personnel radiation

protection be prepared consistent with the requirements of 10 CFR 20 and be

approved, maintained, and adhered to for all operations involving personnel radiation

exposure. On November 2,1996, the licensee did not adhere to the following

radiation protection procedures. )

1. Radiation Protection Procedure RPM 2.1-2 requires in Step 3.1 that health

physics supervision determine whether a new RWP/Jobstep must be initiated

or if an existing RWP/Jobstep is adequate to provide the proper radiological

protection, exposure tracking, and ALARA controls.

On November 2,1996, health physics supervision authorized workers to ,

enter the fuel transfer canal to perform inspections of the fuel transfer l

mechanism and perform housekeeping. The RWP and Jobstep used for this {

task were not adequate to provide proper radiological protection, exposure '

tracking, and ALARA controls. The RWP failed to provide adequate external

and internal exposure controls as well as ALARA controls. Further, the RWP

and Job Step (RWP No. 411, Job Step 13) were not valid for entries into the ,

fuel transfer canal. )

2. Radiation Protection Procedure RPM 2.5-4, requires in Step 3.2 that

radiological controls personnel shall, during the course of the job, check j

conditions at the job site to ensure instructions are being properly followed.

On November 2,1996, radiological controls personnel did not provide health l

physics job coverage for personnel working in the fuel transfer canalin

accordance with procedure RPM 2.5-4, Step 3.2. Specifically, checks of  ;

workers were inadequate to ensure conformance with the understood work l

scope. Consequently, workers were exposed to high concentrations of .

airborne radioactivity and handled debris measuring between 20 R/hr and l

60 R/hr on contact. I

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3. Radiation Protection Procedure RPM 2.1-1, requires in Step 3.1.6 that the

job supervisor provide a description of the work to be performed.

On November 2,1996, the job supervisor, responsible for inspection and

housekeeping within the fuel transfer canal, did not provide health physics an I

adequate description of the work to be performed. Specifically, the job .

supervisor did not inform the health physics department that 1) excess l

grease found in the transfer canal would be used to grease dry bevel gears, j

2) paint chips and associated metal rust would be peeled off the coffer dam l

walls, and 3) dry dirt like loose debris would be grabbed with the hand from  !

the canal floor and deposited into a plastic bag. l

4. Radiation Protection Procedure RPM 2.7-4, requires in Step 2.1 that clothing

contamination reports be completed.

On November 2,1996, clothing contamination reports were not completed  ;

for contaminated workers who exited the fuel transfer canal on l

November 2,1996.

5. Radiation Protection Procedure RPM 1.2-1, requires in Step 3.1, that

Attachment A, Resume Validation and Position Assignments, be completed

to document the actual experience of contractor health physics technicians

in various work activities, including determination of maximum experience  ;

credit permitted for each work category (e.g., job coverage experience). j

The licensee did not complete Attachment A for the contractor radiation

protection personnel involved in the November 2,1996, airborne

radioactivity event.

6. Radiation Protection Procedure RPM 1.6-5, requires in Step 3.1 that the

health physics manager / designee issue a memo announcing the upgrade and j

expected duration of the upgrade of union personnel. l

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in January 1996, a senior radiation protection technician, a union individual, j

was upgraded to the position of acting Assistant Radiation Protection j

Supervisor following departure of the incumbent and, as of November 8,

1996, a memo announcing the upgrade was not issued.

The licensee did not adhere to radiation protection procedures as described above,

and this represents four examples, of failure to adhere to Technical Specification 6.11.

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d. Technical Specification 6.12.2 requires, in part, that in addition to the requirements

of Specification 6.12.1, areas accessible to personnel with radiation levels greater

than 1000 mR/hr at 45 cm from the radiation source shall be provided with lock

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doors to prevent unauthorized entry and doors shall remain locked except during

periods of access by personnel under an approved RWP which shall specify the

dose rate levels in the immediate work areas and the maximum allowable stay time

for individuals in that area.

The licensee did not establish and implement radiation work permits (RWPs) in

accordance with Technical Specification 6.12.2, in that on the morning of

November 2,1996, personnel entered a locked High Radiation Area (reactor cavity

and fuel transfer canal) with accessible dose rates greater than 1000 mR/hr at

45 cm and the RWPs used for the entry did not specify the dose rate levels in the

immediate work areas and the maximum allowable stay time for individuals in that

area. Further, the RWPs were not valid for entry into the fuel transfer canal.

This is an apparent violation of Technical Specification 6.12.2.

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