ML20137G067

Insp Rept 50-271/85-21 on 850809.Violation Noted:Failure to Adequately Communicate Instructions to chemistry-health Physics Technician Resulting in 850808 Unplanned whole-body Exposure

ML20137G067
Person / Time
Site:	Vermont Yankee
Issue date:	08/16/1985
From:	Bellamy R, Pasciak W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:
Shared Package
ML20137G059	List: ML20137G055 ML20137G067
References
50-271-85-21, NUDOCS 8508270163
Download: ML20137G067 (8)

See also: IR 05000271/1985021

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U.S. NUCLEAR REGULATORY COMMISSION

REGION I

Report No. 85-21

Docket No. 50-271

License No. DPR-28 Priority --

Category C

Licensee: Vermont Yankee Nuclear Power Corporation

1671 Worcester Road

Framingham, Massachusetts 01701

Facility Name: Vermont Yankee Nuclear Power Station

Inspection At: Vernon, Vermont

Inspection Conducted: Asgutst 9, 1985

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Inspectors: n .{ (t,f & cb \

W.J.[JascYak, Chief,BWR-

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RadVation Protection Section

Approved by:

_R.

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R. Bellami, Chief, Emergdncy

F//4/P 5'

date

Preparedness and RadiologiBal Branch

Inspection Summary: Inspected on August 9, 1985

(Report Number 50-271/85-21)

Areas Inspected: Special announced inspection of licensee Radiation

Protection Program. The area inspected involved an unplanned whole-body

exposure of a technician on August 8, 1985. The inspection involved 5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br />

on-site by a region based inspector.

Results: One apparent violation was identified (failure to instruct workers

per 10 CFR 19.12, paragraph 3.3).

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8508270163 850820

PDR ADOCK 05000271

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DETAILS

1. Persons Contacted

1.1 Licensee Personnel

Mr. S. Berger, Chem. & HP Technician

• Mr. W. Conway, President &' Chief Executive Officer

Mr. M. Fuller, Chem. & HP Assistant

• Mr. B. Leach, Chem. & HP Supervisor

Mr. S. McAvoy, Chem. & HP Technician

• Mr. J. Pelletier, Plant Manager

Mr. T. Watson, Sr. I&C Engineer

1.2 Yankee Atomic Electric Co. Personnel

Mr. D. McCurdy, Manager, Environmental Laboratory

Mr. N. Stanford, Supervisor, Rad. Dosimetry Section

1.3 NRC Personnel

• Mr. H. Eichenholz, Senior Resident Inspector (Yankee Rowe)

• Attended Exit Inverview on August 9, 1985.

2. Purpose of the Inspection

The purpose of this inspection was to review circumstances surrounding an

unplanned whole-body exposure of a Chemistry & Health Physics technician

performing surveys in the TIP room on August 8, 1985.

3. August 8, 1985 Unplanned Extremity Exposure

3.1 Background

On August 8, 1985, at about 6:30 p.m., a Chemistry & HP Technician

sustained an unplanned whole-body exposure of about 1.3 rem while

performing a survey in the TIP room. The licensee notified NRC by

7:30 p.m. on the same day and suspended further entries into the TIP

room until interim corrective measures were developed by the licensee

and reviewed by NRC. The Chief, BWR Radiation Protection section was

dispatched to the site on August 9, 1985, to review the unplanned

exposure.

3.2 Description

On August 8, 1985, at approximately 6:05 p.m., a request was made by

the Senior I&C Engineer of the on-shift Chemistry & HP Technician

that a radiological survey of the TIP rocm was needed. The survey was

initially requested to determine whether dose rates were low enough

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to allow access to the rcom for repair work. The I&C engineer did

not indicate what the dose rates would be but that they could be

high. (It was expected that dose rates would be high in the room

because one TIP had been stuck in the core earlier that day.) At

approximately 6:10 p.m. the technician met the Assistant I&C Foreman

at the checkpoint. The technician stated that the Assistant I&C

Foreman requested an RWP and that the TIP room would be entered that

night. -

In an attempt to determine the proper procedure to follow to enter

the room, the technician tried tc call several Chemistry & HP Assis-

tants but was unabic to cnntact them. The key to the TIP room was

kept in the HP control point office with other high radiation area

access keys. This key was unlike the other keys as it had a tag

attached to it indicating that the Chemistry & HP Supervisor was to

be called before the key was used. The technician called the Chem-

1stry & HP Supervisor at home and was told that exposure rates could

be as high as 1000 R/hr and to go and enter the room and perform the

survey. The technician was not given specific precautionary instruc-

tions indicating at what dose levels the survey should be terminated.

At approximately 6:25 p.m. the technician called the control room and

asked for assistance from control room staff for entry. The control

room dispatched an Auxiliary Operator to assist the technician on the

entry. Meanwhile the technician obtained the latest survey of the

area. This survey is attached as Figure 1 to this report. The

survey was performed on August 5, 1985, and the highest observed

exposure rate was less than 80 mR/hr. On the way to the TIP room the

technician met a Chemistry & HP Assistant who told him that he once

observed exposure rites as high as 450 R/hr in the TIP room. The

Chemistry & HP Assistant did not provide clear instructions to the

technician regarding specific numerical dose levels at which the

survey should be terminated.

The technician was equipped with a Gertz teletector (GM Chamber) and

a hand held ionization chamber. Upon entering the corridor to the

TIP room he stopped at approximate location "E-F" to extend the tel-

etector probe into location "C" (see Figure 2). The teletector in-

dicated approximately 100 R/hr. He then withdrew the teletector and

made a similar measurement at location "C" with the ionization

chamber which was about 200 R/hr. While making this measurement he

stood b nind the wall at location "0" and extended his arm holding

the instrument at location "C". Next he extended the probe of the

teletector to make measurements near the core probes located at "1",

"2", and "3". The teletector probe was extended at location "D-C"

toward location "B" and "A". The highest exposure rate was measured

at location "B" and was about 1000 R/hr. The exposure rate gradually

decreased as the teletector probe was extended from location "B" to

location "A". At location "A" the exposure rate was about 50 R/hr.

The distance between locations "A" and "C" is approximately 12 feet.

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The technician had to stand at the "C-D" location in order to extend

the teletector across the room, and it is probable that most of the

radiation dose he received was accumulated during this time. The

' technician estimated that the entire time period he was in the high

radiation area was about 2 minutes. The dose on the technician's TLD

badge (1.3 rem) suggests that he was at location "C" for less than

one minute. This is consistent with the technician's description of

his activities.

Upon leaving the TIP room area the technician's self-reading dosi-

meter (500 mrad full-scale) was offscale and the Auxiliary Operator's

self-reading dosimeter read 270 mrad. Processing of the technician's

TLD indicated a whole-body dose of 1.3 rem. The technician's whole-

body dose is likely not to be significantly different from his ex-

tremity dose because the highest sources"were a considerable distance

away from where he was standing during all of his activity in the

area.

The Chemistry & HP Technician had approximately 7 months job exper-

ience at the facility as an HP technician and prior to this he had'no

in plant HP experience. Before beginning his activities as a Chem-

istry & HP Technician he spent several months full-time in the VY

training program. The experience that the technician gained over his

7 month HP employment period did not prepare him for taking appro-

priate precautionary actions upon encountering the exposure rates

that existed in the TIP room. Typically the highest exposure rates

that are routinely encountered at the facility are about 15 R/hr.

Exposure rates of 15 R/hr result in dose rates of a few hundred

mrem / minute, whereas exposure rates present in the TIP room result in

dose rates of 10-20 rem / minute. While the technician may have been

adequately trained and experienced to deal safely with dose rates of

a few hundred mrem / minute, he had never experienced exposure rates of

the level in the TIP room, nor was he adequately instructed by HP

supervision of appropriate precautionary measures should they be

encountered. These circumstances resulted in his unplanned whole-

' body dose of 1.3 rem.

3.3 Findings

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Within the scope of this revfew, the following apparent violation

was identified:

10 CFR 19.12 requires that all individuals working in or

frequenting any portion of a restricted area shall be kept in-

formed of the storage, transfer, or use of radipactive

materials or of radiation and shall be instructed in the health

protection problems associated with exposure to such radiation

and in precautions or procedures to minimize exposure.

Contrary to the above, en August 8, 1985, a Chemistry & HP Tech-

nician was given approval by HP supervision to enter a high-

radiation area to perform surveys where there was a known po-

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tential for unusually high exposure rates and the individual was

not instructed by HP supervision in precautions or procedures -

to minimize exposure. As a result the individual entered the

area where exposure rates measured up to 1000 R/hr and received

an unplanned whole-body dose of approximately 1.3 rem. (50-271/

85-21-01)

4.0 Licensee Corrective Actions

o The Licensee presented interim corrective actions to the inspector. These

actions include the following and were put immediately (August 9, 1985,

6:30 p.m.) into effect:

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Requested the Nuclear Service Department to perform a detailed study

of doses received by the technician and the Auxiliary Operator who

entered the TIP room.

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A whole-body count to be made of the two individuals.

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Read the TLD of the Auxiliary Operator who entered the TIP room.

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Relieve the technician of HP duties until the status of his readi-

ness to perform HP duties is formally reassessed.

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Deteemine if the enclosed space entry provisions apply to the TIP

room. If they do, properly post the room. If they don't, remove

the stenciling which suggests that they apply. This shall be done

prior to any further TIP room entries.

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The following administrative controls regarding TIP room entry were

immediately applied:

• An RWP shall be required for all TIP room entries.

The RWP shall be signed by the Chemistry and Health Physics

Supervisor, the Shift Supervisor and the signature (s) of all

Department Heads who have personnel involved in work under the

RWP. The Chem. & HP Supervisor shall assure that the RWP

specifies in detail the nature of the activities to be per-

formed, the expected dose rates and the action to be taken if

specified higher dose rates are encountered. The Shift S. aper-

visor's signature will indicate his approval to do the spec-

ified work, will indicate trat he has verified that the TIPS

have not been used in the core in the last 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> and will

indicate that the TIP machines have been White tagged to

disable any movement of the TIPS. The other department heads

signatures shall indicate that they have assured themselves

that their personnel working under the RWP are keenly aware of

the potential dose rates that can be encountered in the room,

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that they understand the limitations to the work they can per-

form under the RWP and that they understand the actions to be

. taken if the specified higher dose rates occur.

• Any TIP Room access will include a " rescue man" available at

the doorway to assist in an emergency.

The key to the TIP Room will be kept by the Chem. & HP Super-

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visor and not released for use until he is satisfied all the

above conditions are met.

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A report will be generated to thoroughly document and analyze this

event and to provide recommended long term corrective actions. This

report should also consider the co rective actions mentioned above

and make recommendations regarding them as may be appropriate.

These interim measures were reviewed by the inspector and found to

be adequate.

5.0 Exit Interview

The inspector met with licensee representatives (denoted in Section 1) on

August 9, 1985. The inspector summarized the purpose, scope and findings

of the inspection. At no time during the inspection did the inspector

provide written material to the licensee.

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