ML20137M803
| ML20137M803 | |
| Person / Time | |
|---|---|
| Site: | Saint Lucie  |
| Issue date: | 08/03/1995 |
| From: | Jimenez M, Voorhees J, Walls J FLORIDA POWER & LIGHT CO. |
| To: | |
| Shared Package | |
| ML20137M095 | List: |
| References | |
| FOIA-96-485 QSL-OPS-95-10, NUDOCS 9704080184 | |
| Download: ML20137M803 (16) | |
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- s FPL Nuclear Division j Quality Assurance Audit Report g
St. Lucie Plant i
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RADIATION PROTECTION FUNCTIONAL AREA AUDIT l QSL-OPS-95-10 l
l Audit Team:
J. J. Walls Quality Assurance M. A Jimenez Corporate Health Physics L. W Bladow QA PSL i
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- } AUDIT REPORT g k/' QSL-OPS-95-10 Page 1 of 13 Executive Summary This audit was conducted to evaluate program adequacy and assess the implementation of activities associated with St. Lucie Radiological Protection Program. The conclusions of this atidit are based on interviews with personnel, review of procedures and records, and observation of health physic activities. Many of these activities were documented in monthly Performance Monitoring Reports. Program adequacy was evaluated by comparison of site procedures, records and traming lesson plans to guidance documents in addition to review of these documents, field observations and attendance in classroom training provided the opportunity to evaluate the implementation of the site procedures, generation of records and health physics lesson plans. Activities that have been observed include
- radiation field and contamination surveys, counting room activities, gaseous and particulate atmospheric surveys, postings, worker compliance to the Radiation Work Permits, ALARA review, pre-job briefings, preparation of radioactive material shipments, and tours of the Radiation Control Area to observe the transport and storage of radioactive material. Class room presentations observed included General Employee Traming, Radiation Control Area Access Training and Emergency Radiation Team Trainmg.
Assistance from Corporate Health Physics provided an examination of the Intemal Dose Monitoring and Total Effective Dose Equivalent (TEDE) As low As Reasonably Achievable
( ALARA) Evaluations The resuhs of this review developed some suggestions for improvement that were given to Health Physics This evaluauon included a review of St Lucie NRC Inspecuon reports for Radianon Protection, NRC monthly Resident Inspector Reports and State of Florida Department of Health and Rehabihtative Services mspection reports of radioactive waste shipments. No violations have been cited m these reports These external observations have indicated sansfactory performance and provided favorable comments.
Several self assessments were determined to be in progress Health physics has completed at least one documented self assessment This review examined conduct of resin dewatenng operations and contained several recommendauons for improvements The ALARA program provides for regular evaluauon of jobs to identify opportunities to reduce personnel exposure. This program has been successful in achieving reduced exposures Corrective Action within' health physics was examined. St. Lucie Action Requests (STARS) assigned to health physics were reviewed and determined to provide adequate corrective measures Additional corrective action mechanisms within health physics mclude Skin and Clothmg Investigations and Radiological Deficiency Reports. A trend was observed within recent Radiological Deficiency Reports regardmg entry into the RCA without electronic dosimetry. A STAR was imuated to address this trend QA recommends that periodic trend reviews of
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1 AUDIT REPORT QSL-OPS-95-10 plllp3L Page 2 of 13 radiological deficiencies be performed and guidance be developed to initiate STARS for trends or radiological deficiencies requiring increased management attention.
A Good Practice which was noted was the management control that Health Physics has been given to control work in the containment. A site procedure HPP-23 " Health Physics Activities in the Reactor Containment Building During Shutdown" was written and distributed to provide guidance to HP in establishing early radiological controls upon start of containment refueling outage work.
Based on the activities and objective evidence audited, it was determined that the requirements of the St. Lucie Radiation Protection Program were adequately addressed by procedures and the implementation of those procedures was effective.
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E Page 3 of 13 Location of Audit St. Lucie Plant Date of Audit April - June 1995 Audit Scope .
This audit evaluated the program adequacy and implementation of activities associated with Radiological Protection. The scope of this audit included the following:
A. Verification that the necessary procedures exist and comply with 10 CFR, 49 CFR, FSAR, Emergency Plan and the Technical Specifications.
B Analysis of LER's, problem reports, in-house events, NRC inspection reports associated with radiological protection.
C. Review of the effectiveness of Health Physics'self assessment activities.
D. Assessment of the effectiveness of corrective action activities within Health Physics.
E. Verify implementation of the Health Physics's requirements not verified through recent performance monitoring activities.
F. Examination of the use of industry information relating to Health Physics.
Audit Details Program and Procedure Evaluation The revised 10 CFR 20 instituted changes that involved administrative and physical requirements for heensees to protect personnel from radiation exposure. The transition to the "New Part 20" requirements were venfied dunng recent Performance Momtonng activities and this audit. NRC Inspection Manual Temporary Instruction 2515/123 " Implementation of the Revised 10 CFR Part 20" was used to evaluate the plant implementation of these new requirements.
Procedures were reviewed to verify that the new requirements of 10 CFR 20 have been included-Procedures for radiation . postings, access to high, locked high and very high radiation areas, radiation, contamination and airborne surveys, ALARA requirements, radioactive source control and labeling, and occupational dose limits were determined to contain new nomenclature and reqmrements No deficiencies were identified.
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s AUDIT REPORT g (k ') QSL-O PS-95-10 Page 4 of 13 Training for the new part 20 requirements vias evaluated by attending classes or review of training outlines. Topics reviewed included emergency radiation team training, radiation control area access training (initial and annual requalification), and training for health physics technicians, supervisors and administrative personnel. Attendance rosters were reviewed for adequate record keeping.
The use of Merlin Gerin electronic dosimete:s for accounting of personnel exposure was evaluated by procedure review and observation of usage. Health Physics Procedures reviewed were: HPP-30," Personnel Monitoring" and HP-74," Access Control Using Alarming Dosimeters."
These procedures included applicable requirements of 10 CFR 20. A review was conducted of the 50 59 Safety Evaluation performed to allow the use of these alarming electronic dosimeters.
The PSL FSAR discusses use of the self reading pocket dosimeter only. It was further verified through discussion with Nuclear Engineering and Licensing that changes to the FSAR that include this form of dosimetry will be published in this year's amendment. The use of these dosimeters was found acceptable.
Technical assistance for this audit was provided by the Juno Beach Health Physics Staff. Their evaluation covered Internal Dose Monitoring as required by the New Part 20. Requirements reviewed included methods of internal dose calculations, assignment of DAC-hours, issuance of respiratory protection devices, and those for personnel monitoring as outlined in procedure HPP-30 " Personnel Monitoring" General comments on areas of improvement were copied to the Health Physics Department. During this review it was noted that an individual had issued respirators who did not possess qualifications in this area. This individual was a jumor technician with a limited authorizanon in work assignments. Appropriate training modules for this activity had not been completed. Research indicates that this occurred only on one day and that the personnel that were issued the respirators were qualified to use them. This was considered an isolated event. Corrective action for this occurrence has been implemented. Only qualified junior techmcians will be allowed to issue respirators in the future. This activity will be the subject of a Performance Momtonng Activity dunng the next refueling Corporate Health Physics reviewed the program for Total Effective Dose Equivalent (TEDE) As Low As Reasonably Achievable (ALARA) Evaluation. This consisted of review of procedures and records specific to respiratory protection. No TEDE ALARA evaluations were performed in 1994 The critena for documenting the evaluations was not met for any o.f the jobs performed dunng the year. This program was determined to be satisfactory The quality assurance requirements of 10 CFR 71.105, Transport of Radioactive Matenal, were venfied to be in place for radioactive matenal shipping Plant procedures were venfied in place and documents were reviewed for orgamzation, procurement, procedures, controlled documents, material control, receipt inspection, identification & control of matenal, qualified inspectors, control of measuring and test equipment, and records Radioactive matenal shipping has been examined during Performance Monitonng activities This program is considered adequately established and implemented.
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Page 5 of 13 The general requirements of the Radiation Protection Program were verified through procedure review, record review and field observation. The activities verified include radiation surveys and postings, Radiation Work Permit requirements, proper use of dosimetry, Posting of Notice to Workers (NRC Form 4), handling and shipping of radioactive material, and sealed source control. l A summary of the field observations which have been conducted is provided in the Performance Mor.itoring Section.
Analysis of NRC Documents and Industry Information A review of NRC inspection reports indicates that no health physics violations have been issued to St. Lucie Plant in 1994/95. This review included four NRC Inspection Reports that were specific to Health Physics and monthly NRC Resident Inspectors reports. There were no LER's wntten due to Radiation Protection activities Health Physics participated in corrective action for an LER that was due to other causes This LER 389 95 003, was written due to a missed surveillance test by another department. Corrective action required other departments to check their scheduling for improvement opportunities Changes to Health Physics schedules were not required. Industry Violation Alerts have been examined dunng Performance Monitoring activities to verify that activities at St. Lucie did not provide the same potential for citation. l An additional rule change to 10 CFR 20 was published during this audit (FR67657). A PSL
- STAR was initiated to track the review by the Health Physics Staff for determination that the change did not require any PSL program changes. This rule change carried forward the old Part j 20 record retention not published in the new Part 20. St. Lucie's record retention requirements for Health Physics records were verified to be life of the plant and required no program or f procedure changes. Health Physics was associated with one In House Event. This event (Ref. l Problem Report 95-14) and corrective action involves Health Physics removing resin beads from )
the spent fuel pool. Completion of this activity was verified by chemistry and documented on l 6/9/95. All items were considered satisfactory.
Another outside agency that performs inspections of the Health Physics Department is the State of Flonda Department of Health and Rehabilitative Services. This mspection is done on radioactive waste shipments leaving St. Lucie Plant using 49 CFR as acceptance criteria. A review of 11 Radioactive Matenal Shipment Record Packages found five of these records were radioactive waste shipments A review of the HRS inspection reports and discussion with Health Physics showed that the State of Flonda inspections of Radioactive Waste Shipments from St. l Lucie Plant were satisfactory. l l
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~ QSL-OPS-95-10 Page 6 of 13 Performance Monitoring Activities The following Radiological Protection topics have been reviewed through the conduct of performance monitoring activities during 1994 - 95:
New 10 CFR 20 implementation General Employee and Radiation Access Training of New Part 20 Posungs and Radioactive Material Control
- Radioactive ' Waste Shipping Radianon Surveys Health Physics Measuring and Test Equipment Survey and Release of Clean Waste from the Radiation Control Area Merlin /Gerin Electronic Dosimeter Procedures and Implementation Radiation Work Permit Compliance !
Radioactive Source Control Sealed Source Leak Testing 4 l
l High, Locked liigh W Very High Radiation Area Control 1
Emergency Radiation Team Training !
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Hazardous Material Certification for Shipping Personnel i 1
1 Health Physics Techmcian Training )
1 Radiation Monitor Alarms, Setpo..nts, Calibration and Surve.llance Centrol of PC-1 Resin Liners for Radwaste Shipping 7, Receipt and Inspection of New Fuel Assemblies l
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{ ) g v ./ QSL.O PS-95-10 Page 7 of 13 These activities were physically verified in the plant or classroom to determine compliance to valid requirements. Observation of plant maintenance and operations personnel has indicated satisfactory compliance with Health Physics procedures and requirements.
The above performance monitoring activities resulted in the identification of four audit findings.
The subject of the findings were: Inadequate criteria for inspection hold points for Radioactive Material Shipping, Radioactive Sources not labeled according to the FSAR and 10 CFR 20, Special Nuclear Material not stored in a designated space, and PC-1 Radwaste Resin Liners were released for use prior to receipt inspection. Corrective action for these fmdings will be discussed in the Corrective Action Section.
A Good Practice which was noted was the management control that Health Physics has been given to control work in the containment. A site procedure HPP-23 " Health Physics Activities in the Reactor Containment Building During Shutdown" was written and distributed to provide guidance to HP in establishing early radiological controls upon start of containment refueling outage work. Additional controls such as evacuanon of the 62' elevation dunng the reactor head lift have been proceduralized This practice contributes to exposure control and personnel safety.
Sell' Assessment Ilealth Physics personnel recently performed a formal, documented self assessment. It was indicated by Health Physics that formal assessments would be more common in the future The recent self assessment was conducted on resin dewatering of radioactive bead resin. This assessment was prompted by a Quahty Assurance Audit No QSL-OPS 95-04. The assessment contained recommendations for improvements and is pending implementation.
The ALARA Prvam acts as a self assessment technique to identify methods to reduce the exposure of personnel working m the Radiation Control Area. Histoncal files of repetitive activities have been rnaintamed since 1987. These files contain man hours, exposure, RWP number, notes on technique and general comments to assist in providing experience to improve performance. This history file is used dunng the next pre-job bnefing to assist the workers and Health Physics in reducing exposure A pre-job ALARA rriew, usmg present survey information and the h'istory file, is conducted to develop a proper pre-job briefmg for all participants. A post outage assessment of repeated jobs is conducted to compare exposure to a target. A report is produced which contains a review of all jobs with assigned dose greater than 1 manrem whose actual manrem differed from their projected manrem by more than 25% This system has provided a positive impact on dose reduction at St. Lucie Plant. This program is considered effective as a self assessment tool to reduce radiation exposure.
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\/ QSL-O PS-95-10 Page 8 of 13 Corrective Action St. Lucie Action Reports (STARS) assigning corrective action responsibility to Health Physics were reviewed. The source of these STARS include Feedback of Operating Experience Program (FOP), Quality Assurance Audits, Quality Control Surveillance Reports, changes in federal laws, and In House Events.
Selected 1994/95 STARS were discussed with Health Physics. Objecnve evidence of corrective action was reviewed in selected areas. These items mclude FOP 94-004/SOER 94-2 which required HPP-23 to be revised, WANO area for improvement RP 2.1 which recommended area radiation monitors at primary sample smks, and Licensee Event Report LER 389-95-003 which required a check of survedlance scheduling to verify Tech Spec. Surveillance intervals.
Completed correenve action was ven6ed to be still in place. Other acnons that are in the implementation phase were reviewed and will provide acceptable correenve action when carried out Quality Assurance Findings written in the last year were reviewed for continued implementation of corrective action. An audit finding which identified inadequate acceptance criteria for inspection hold points for radioactive material shipments was corrected by revising the procedure to including valid requirements for inspecting attributs M these shipments Radioactive Sources not labeled according to the FSAR and 10 CFR 20 were corrected by performmg an inventory I and affixmg the new labels with required infonnation This was verified by performance monitonng during the next inventory and source leak test. Special Nuclear Material not stored m a designated location was discovered during review of the inventory record review. The :
procedure was revised to include all areas used to store these materials. PC-1 radwaste resin i liners were identified as having been released for use pnor to receipt inspecnon. Correenve f action involved receipt inspection of the liners and review of the procedure with stores and mamtenance personnel Implemented corrective action for QA audit findings continues to satisfy the fmdings A review of discrepancies identified on Quality Control surveillance reports was conducted. Four (
unsatisfactory condinons were identified in the past year during Health Physics inspections.
They melude: records missmg required data. emergency lockers contaming less than mmimum required equipment, a nitrogen bottle not adequately stored, and HPP 1.4 form not always bemg completed when exiting the containment These issues were discussed with the QC surveillance supervisor. It was determined during subsequent surveillance opportumties that corrective action was adequate and these items had been corrected.'
A correcuve action process specific to the Health Physics program is Skin and Clothing Contamination invesuganons. These investigations are documented on Form 70.1. This form mcludes personal mformation on the individual, location of contamination, description ofincident, HP technical evaluation, countermeasures to prevent recurrence and signatures of personnel
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Page 9 af 13 involved, including the Health Physics Supervisor. Ten completed record forms were reviewed.
These were generated during 1994/95. The forms were complete and countermeasures, where applicable, were adequate.
The other process used by the Health Physics Staffis HP-101.2 Radiological De6ciency Report.
This report is used to document deficiencies of a relatively minor nature such as nondeliberate violations of HP procedures or poor radiological work practices. This form, along with any 1 supporting documentation, records the description of the event, action taken to prevent recurrence and signatures of personnel involved including the Health Physics Supervisor. Seventeen reports have been issued in 1995. These reports were reviewed for completion and adequacy of corrective action. Nine of these reports concerned the use of the Merlin electronic dosimeters.
The deficiencies cited included improper wearing of the dosimetry and entry into the RCA withaut a Merlin dosimeter. The Health Physics Department anticipated personnel errors when use of electronic dosimetry and elimination of the RCA common access point was implemented.
Technicians were stationed at the entry to the RCA to monitor performance. There were no indications that personnel repeated their mistake once counseled by Health Physics Based on the -
number of entries into the Radiation Controlled Area on a daily basis, the number of occurrences was considered small. The level of management review and attention these de6ciency reports receive was discussed with HP. It was noted that these reports receive limited review and 4
management awareness when compared with nonradiological deficiencies identified by the STAR process QA recommends periodic trending and the development of guidance for utilizing the STAR process when increased management awareness or attention is warranted to address trends in radiological deficiencies. An alternative would be to incorporate this process into the STAR program. This recommendation was discussed with HP supervision.
Conclusion Based on the activities and objective evidence audited,it was determined that the requirements of the St Lucie Radiation Protection Program were adequately addressed by procedures and the implementation of those procedures was effective.
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- AUDIT REPORT QS L-OPS-95-10 Page 10 of 13 Satisfactory Areas Health Physics Procedures Health Physics Training Surveys and Postings High Radiation Area Control ALARA Implementation of New Part 20 Measuring & Test Equipment ,
Radioactive Material Shipments Radiation Work Permits and Compliance Personnel Monitoring Findings: None 4
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(__ )1 QSL.O PS-95-10 Page 11 of 13 Audit Participants Department / Group A B C MAH!1 D. A. Sager Site Vice President X C. L. Burton Plant General Manager X J. Scarola Operations Manager X X H. Mercer Health Physics X X H. Buchanan Health Physics X X L. Large Health Physics X X R. McCullers Health Physics X X L. Pugh Health Physics X B. Sommers Health Physics X Health Physics X X j K. Payne L. Jacobus Health Physics X l X l A. W eir Health Physics B. Johnson Health Physics X X l
K. Mouring Health Physics X D. Haithcox Health Physics X J Danek Corporate Health Physics X X M Jimenez Corporate Health Physics X D. Lowens Quality Assurance X L. Bladow Quality Assurance X B Parks Quality Assurance X l J. Walls Quality Assurance X X l K Wecek Quality Control X l J Liefhelm Training X T Ware Training X M Cooper Training X Key:
A - Pre-Audit Conference :
B - Interviewed or Contacted Dunng Audit C - Attended Post Audit Conference 4
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References:
10 CFR 19 10 CFR 20 10 CFR 50 10 CFR 71 4
49 CFR 170-173
'St. Luc'ie Plant Units I and 2 Technical Specifications St. Lucie Plant Units I and 2 Final Safety Analysis Report St Lucie Plant Health Physics Procedures I
Pre-Audit Conference: Post-Audit Conference:
Location: St. Lucie Plant Location: St Lucie Plant Date: April 18,1995 Date: July 26,1995 l
l Summary of Post-Audit Conference: )
The results of the audit was discussed with those in attendance. There were no dissenting comments Location of Audit St Lucie Plant
( AUDIT REPORT I 7 Qg QSL-OPS-95-10 Page 13 of 13 l
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uditor: h [
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Accompanying /. Y Auditor: [ jimenez p Date' /
Corporate Health Physics i Reviewed By: .
[3 b J. Voorhees Date
. Supervisor - PSL f
Approyed By:
L. W. Bladow Date Site Quality nianager - PSL E
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QUALITY ASSURANCE DEPARTMENT f r AUDIT REPORT DISTRIBUTION ,
AUDIT REPORT: QSL-OPS-95-10 PLANT / DEPARTMENT: St. Lucie Plant NUMBER OF FINDINGS: None CNRH Additional Distribulian R. J. Acosta - JNA/JB J. H. Goldberg - JEX/JB W. H. Bohlke - JPN/JB T. V. Abbatiello - JNA/PTN
- J. E. Geiger - JNA/JB L. W. Bladow - JNA/PSL D. A. Sager - VP/PSL-1 R. A. Symes - JNA!JB T. F. Plunkett - VP/PTN D. A. Culpepper - JPN/JB G. J. Boissy - JPN/JB QAD Files w/ Checklist & Audit Plan Cheryl Robinson - JNA/JB 1 Dr. K. R. Craig - JPN/JB l Health Phys!cs & Chemistry Related Audits
- 11. N. Paduano - JPN/JB Manager Nuclear Health Physics / Chemistry Dr. W. R. Corcoran (CNRB) Emereenev Prenaredness Related Audits l Manager - Nuclear Emergency Preparedness S. E. Scace (CNRB)
Fire Prottstion Audits K. E. Gutowski - JNA/JB S. Martin. Risk Management Additional Distribution Nuclear Division Staff Related Audits D.11. West C. Burton - Plt. MgrdPSL R. Prevatte NRC/PSL Nuclear Trainine Related Audits
- 11. Buchanan - HP/PSL Manager Nuclear Training J. Scarola - OPS /PSL J. Danek - JNO/JB Security Related Audits
- Manager Nuclear Security ;
. 1 Nuclear Materials Management Related Audits l Director Nuclear Materials Management
- Only Distribution outside the Plant for Security audits Containing Safeguards sw ,
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I Inter-Office Correspondence FPL JQQ-95-136 To: C. L. Burton Date: August 3,1995 From: L. W. Bladow Department: JNA/PSL
Subject:
Quality Assurance Audit OSL-OPS-95-10 Attached is the report of a functional area audit conducted to assess the adequacy and implementation of Radiation Protection Programs at St. Lucie.
There were no findings in this audit and as such no response is required.
We sincerely appreciate the cooperation we received from your staff during the course of the audit. Please contact me at extension 4190 or the respective QA contact if you have any questions.
M L. W. Bladow l Site Quality Manager - PSL LWB/JTV/JJW/str Copies to: Dist. Attached l
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