ML20132G615
| 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: |
| 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:
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A special reactive safety inspection was conducted by personnel from the NRC Region 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
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
to Mr. J. Hasettine, also of your organization, on November 22,1996. Additionally,
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
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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
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ADOCK 05000213
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Mr. Ted C. Feigenbaum
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extended period. Further, we are concerned that your staff failed to recognize that a
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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
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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
Practice," a copy of this letter and enclosures will be placed in the NRC Public Document
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Room (PDR).
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Sincerely,
0@ina(&nd$y:
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James T. Wiggins, Director
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Division of Reactor Safety
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Docket No. 50-213
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Enclosures:
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1. Executive Summary and List of NRC Concerns and Apparent Violations
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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
J. Thayer, Vice President - Nuclear Engineering and Support Recovery Office
F. C. Rothen, Vice President - Work Services
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J. J. LaPlatney, Haddam Neck Unit Director
L. M. Cuoco, Senior Nuclear Counsel
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
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Distribution w/ enc!s:
Region 1 Docket Room (with concurrences)
D. Screnci, PAO
J. Rogge, DRP
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NRC Resident inspector
M. Conner, DRP '
C. O'Daniell, DRP
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J. White, DRS
R. Nimitz, DRS
J. Wiggins, DRS
D. Holody, Enforcement Coordinator, RI
D. Chawaga, SLO
Nuclear Safety Information Center (NSIC)
PUBLIC
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DRS File
Distribution w/encls (VIA E-MAIL):
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J. Liberman, OE
F. Davis, OGC
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F. Miraglia, NRR
R. Zimmerman, NRR
Enforcement Coordinators
RI, Ril, Rlli, RIV
W. Dean, OEDO
P. McKee, NRR/PD l-4
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
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DATE
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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.
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Plant Support:
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Plant management and staff failed to effectively plan and control radiological work
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
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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
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
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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.
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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
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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,
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such an evaluation includes a physical survey of the location of radioactive material
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and measurements or calculations of levels of radiation or concentrations or
quantities of radioactive material present.
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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
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20.1201, were not adequate as follows
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1.
On November 2,1996, two workers in the fuel transfer canal unknowingly
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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
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limits.
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2.
On November 2,1996, airborne radioactivity surveys were not adequate to
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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
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 ).
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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 cm of removable
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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.
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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.
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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
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enter the fuel transfer canal to perform inspections of the fuel transfer
mechanism and perform housekeeping. The RWP and Jobstep used for this
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task were not adequate to provide proper radiological protection, exposure
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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
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fuel transfer canal.
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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
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conditions at the job site to ensure instructions are being properly followed.
On November 2,1996, radiological controls personnel did not provide health
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
scope. Consequently, workers were exposed to high concentrations of
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airborne radioactivity and handled debris measuring between 20 R/hr and
60 R/hr on contact.
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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
adequate description of the work to be performed. Specifically, the job
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supervisor did not inform the health physics department that 1) excess
grease found in the transfer canal would be used to grease dry bevel gears,
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2) paint chips and associated metal rust would be peeled off the coffer dam
walls, and 3) dry dirt like loose debris would be grabbed with the hand from
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the canal floor and deposited into a plastic bag.
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
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).
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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
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expected duration of the upgrade of union personnel.
in January 1996, a senior radiation protection technician, a union individual,
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was upgraded to the position of acting Assistant Radiation Protection
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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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