ML20141A004

Independent Assessment of Radiological Controls Program at Cyap Haddam Neck Plant Final Rept May 1997

ML20141A004
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Site:	Haddam Neck File:Connecticut Yankee Atomic Power Co icon.png
Issue date:	05/31/1997
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ML20141A000	List: CY-97-067, Forwards Independent Assessment of Radiological Controls Program at Cyap Haddam Neck Plant Final Rept May 1997. Assessment Performed IAW CAL ML20141A004
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NUDOCS 9706200042
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Text

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Independent Assessment ofthe Radiological Controls Program at the CONNECTICUT YANKEE ATOMIC POWER COMPANY ,

HADDAM NECK PLANT 1

l Final Report 5/97 MILLENNIUM SERVICES, INC.

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DR DOC 05000 13 P PDR

Independent Assessment ofthe Radiological Controls Program at the gg CONNECTICUT YANKEE

%I ATOMIC POWER COMPANY HADDAM NECK PLANT March- April,1997 Final Report Performed by:

l Millennium Services, Inc.

1579F Monroe Drive, Suite 509 Atlanta, Georgia 30332 (770) 955-6395 MILLENNIUM SERVICES, INC.

Leading the way .

Table of Contents j EX EC UTIVE S UM MA RY...................................................................................... iii INTR O D U CTI O N..... ........ ....... ................. .............. ...... . .............. .. ... . ... v 1.0 ORGANIZATION AND MANA GEMENT ................................................... I 2.0 PERSONNEL TRAINING AND Q UALIFICATION .................................. 6 3.0 EXPO S URE M O NITO RIN G ................................... .................................... I 1 3.1 External Exposure Monitoring... .............. ........ ... . ....... .......... ... ........ I 1 3.1.1 . Dosimetry Program . . . . . . . . . . . . . . . . . . . . .. .. . . . . . . . . . . . . . . . . . . . . . . I 1 3.1.2 Exposure Review .. . ... .. ........ . .... .... .... ...... . .............19 3.2 Internt1 Exposure Monitoring....... ... . ....... ........ ... . .... ......... .23 3.2.1 Dosimetry Program...... .. . . . . . . . . .... . . . . . . . . . . . .. 23 3.2.2 Records and Reports / Quality Assuranee..... ... ..... ... .... .. . .31 3.3 Respiratory Protection Program.. ..... .. .... .... . .. . . . . . . . . . . . . . . . . . . ... 33 4.0 SURVEYS.......................................................................................................40 4.1 Routi ne S u rveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......40 l

4.2 Surveys In Support of Radiation Work Permits (RWP) ...... .. ... . .43 5.0 PO STING A ND A REA CONTR O LS............................................................ 47 6.0 INSTR UM ENTATIO N .................................................................................. 51 6.1 Suit ability and Use . ..... . . .. .. . . . . ... . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . 51 6.2 Calibration, Maintenance, and Facilities........ .. .... ..... .......... .. .... . ... . 53 6.3 Quality Assurance ........ .. ........ ....... . .. . .. ... ... . . . . . . . . .......57 7.0 CONTAM IN ATION CONTROL.... ............................................................. 60 7.1 Area Contamination Control... ... ....... . .. .. .. ....... ... ....... .... . ....... 60 I

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Table of Contents 7.2 Equipment & Material.. .. .. . .. .... . . .. . . .. .. . ... . . .... . . .. . . .. . 62 7.3 Personnel Contamination Monitoring... .. . . . . . .. . . . ..........67 8.0 W O RK C O NTR O L. ...... .. .. ... ........ ....... . .... . ..... .... .... .......... .. .. . . . .. .... ...... ....... .. .. 71 8.1 Planning and Scheduling....... ... . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71 8.2 Radiation Work Permits (RWPs).. .. .. . .......... ..... . . . . . . . . . . . . . . . . . 73 8.3 AL ARA Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 0 9.0 RADIOACTIVE WASTE SIIIPPING AND HANDLING.............. ........... 83 9.1 Packaging of DAW . . ...... . .. ... . .. .. . ... ... . . . . . . . . ... . .. .. 83 9.2 Packaging of Resin..... .... . . . .. . .. .... . . ... .. . . . . . . . . . . .. ... 84 9.3 Trai ni n g . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 6 9.4 S h i pp i n g . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 9.5 10CFR61 Review.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... .......87 9.6 Process Control Program.. . . . . . .. .. . . . ... ...... . 89 10.0 RA DIO LOGICA L OCCU RRENCES ... ........................................................ 92 11

EXECUTIVE

SUMMARY

An independent assessment of the Connecticut Yankee Atomic Power Company's Haddam Neck nuclear station Radiation Protection Program was conducted by Millennium Services, Inc. The assessment period spanned the months of March and April,1997. The assessment was in response to a Confirmatory Action Letter (CAL) issued by the Nuclear Regulatory Commission following radiological incidents that had occurred during the period of November 1996 to February 1997. The Haddam Neck plant has been shutdown since mid-1996 and all fuel has been ofiloaded and is stored in the spent fuel building. Northeast Utilities has announced that the facility will be decommissioned. Presently, the plant continues to be governed by the operating license and the Technical Specifications.

The assessment wr.s conducted by Health Physicists with extensive experience in the management and evaluation of radiation protection programs, including two Certified Health Physicists, and a former Nuclear Regulatory Commission inspector. The performance based assessment was structured using the basic elements contained in Guideline INPO 91-014, Revision 1, Guidelines for Radiological Controls at Nuclear Power Stations, and the Management Oversight Risk Tree (MORT) method described in NUREG-0855.

The assessment focused on the elements of an operational health physics program Emphasis was placed on the organizational stmeture, including responsibilities, authorities, and accountabilities.

Program documents, including station procedures, that derme the management structure were evaluated and compared against field practices. Observations and data reviews of methods used to define the radiological hazard, communicate that hazard, establish radiological control requirements, and monitor exposures were evaluated. The assessment included the station work control process and its interface with the Health Physics Department and support services such as l instrument calibration, dosimetry processing, and training.

l The assessment report contains findings, conclusions, and recommendations for each of the program elements. The assessment of the individual program elements identified issues considered to be root causes. Specifically:

Failure to adequately assess the impact of station changes in mission, organization and stafling on the health physics department's ability to implement a functional program, The lack of clear definition of responsibilities, authorities, and accountabilities for program elements; The lack of program documents that describe management stmeture, program commitments, and methods to meet those commitments; Failure to establish rigorous standards for execution and documentation of field health physics activities, including surveys, postings, RWPs; iii

Insuflicient self assessment by the Radiation Protection Department to identify and correct problems and to reinforce strong performance; Inability to hold people accountable; and Inadequate integration of radiological protection into station work procedures and programs.

s The most significant recommendations involve:

Development and stalling of a functional organization; Development of controlling program document and reorganization of procedures;

• Delineation of challenging performance standards; Implementation of processes to monitor and reinforce expectations in the field; and Implementation of training processes in support of program changes.

l Preliminary findings have been presented to the recently hired Health Physics Manager. The manager has commenced several activities in support of the recommendations of this assessment, including the development of a mission statement for the organization and a functional organization. These efforts are consistent with the critical needs identified in this assessment.

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l It is the opinion of the assessment team that the existing organizational structure and resources l are capable of supporting the limited activities presently challenging the Health Physics Program.

The limited activities planned for the near future afford the opportunity to methodically implement the changes necessary to effectively execute the organization's mission in support of the decommissioning project.

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t INTRODUCTION In response to a confirmatory action letter from the U.S. Nuclear Regulatory Commission .

(USNRC) dated March 4,1997, Millennium Services, Inc. (MSI) was contracted by the Connecticut Yankee Atomic Power Company (CYAPC) to perform an independent assessment of the quality and performance of the Radiation Protection / Radiological Controls Program at the Haddam Neck Plant (HNP). MSI recognizes that the CYAPC objective for the HNP involves Decontamination and Decommissioning (D&D) of the site. However, this assessment focused on the operational Health Physics program and key interfaces of program as they were in the current program structure for an operational commercial nuclear power reactor.

This broad scope, performance based assessment was structured using the Management Oversight Risk Tree (MORT) method. The assessment addressed selected functional elements contained in NUREG-0855, Health Physics Appraisal Program, and INPO document 91-104, Revision 01, Guidelinesfor Radiological Protection at Nuclear Power Stations. Millennium Services, Inc., in consultation with CYAPC management, defined the following functional elements to be included in the assessment:

1. Organization and Management (Including Self-Assessment);

2. Personnel Training and Qualification;

3. Internal and External Exposure Monitoring;

4. Survey Program 5 Posting and Area Controls;

! 6. Instrumentation; l 7. Contamination Control; l 8. Work Control;

9. Radioactive Waste Shipping and Handling;

10. Radiological Occurrences The management and organizational structure of the Health Physics Department, staff qualifications, present scope of responsibilities, interface with other plant departments, and the mission of each functional area were reviewed to assist in establishing the depth and nature of the review required in related functional arear.

The applicable standards of acceptability were defined for each functional element evaluated.

Information was obtained by reviewing available documentation (e.g., procedures, Quality Assurance evaluation reports, NRC Inspection reports, training material, records, etc.), detailed interviews with plant stafrand management, and field observation of the performance of Health Physics and radworker personnel. Conclusions as to the degree of adherence to requirements and the quality of performance in the functional areas were based upon a comparison of collected facts and "as found conditions" with the pre-defined standards and the professional judgement of the reviewers. Using the conclusions as a basis, MSI developed recommendations for each functional area where improvement actions were deemed prudent or necessary. These improvement actions identify any program or organizational weaknesses which were or are in violation of good health physics practices or regulatory or plant requirements, or which resulted v

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in adverse effects on worker health and safety, as well as those findings considered precursors to radiological controls or regulatory problems. These recommendations are presented in a manner to facilitate evaluation by CYAP management and subsequent action item closure.

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1.0 ORGANIZATION AND MANAGEMENT 1.1 Backeround The assessors reviewed procedure RPM 1.6-8, Connecticut Yankee Health Physics Organization, Rev. 5, dated 6/16/95, held discussions with members of the health physics organization and observed work practices to assess the adequacy of the organizational aspects of the HP Group.

1.2 Findines The present Radiation Protection Department organization is defined in procedure RPM 1.6-8 and in the " Interim Organization Chart" issued by plant management. Several differences were noted between the two documents. The " Interim" organization modified functional and reporting responsibilities such that the Radiological Engineering and the Radioactive Material Handling groups no longer report to the Health Physics Manager. Although the functional j responsibilities of the Radioactive Material Handling group did not change, the Radiological l Engineering group no longer provides direct support to the Health Physics organization.

l New position descriptions geared toward the decommissioning project have been developed for upper management positions, including the Health Physics Manager, but have not yet been generated for other positions within the Radiation Protection Depanment. Existing position descriptions include positions that are not presently staffed and define responsibilities in general terms, rather than details associated with the functional areas of the health physics program.

, The Radiation Protection Department staff has undergone a number of changes since the l decision to decommission the plant was announced in 1996. The Health Physics Manager position has been filled by several individuals since October of 1996. At the start of the assessment, this role was filled by the former Radiological Engineering Supervisor in an acting capacity. In March 1997, a temporary HP Manager was contracted, and the acting manager assumed a support role. In April 1997, a permanent Health Physics Manager was hired and arrived on site.

During the assessment process, efforts to identify individuals responsible for specific program elements, frequently led to circuitous paths with several individuals assuming responsibility for various portions of the functional area. In many instances, staff personnel stated that responsibilities had previously been assigned to individuals who had left the station, or who were internally reassigned. As a result, the remaining staff members assumed tasks that were i known to be required. There was no indication that an evaluation had been conducted to determine the availability of these individuals to complete additional tasks, or to establish the priorities to which they were expected to work.

Until the arrival of the permanent Health Physics Manager, the department lacked clear direction in the form of a mission, or short and long term goals. This lack of department direction was evident in the fact that priorities were being established on an individual basis, l'

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without the overall guidance necessary to assure that resources were being applied to the most critical department issues. Additionally, tasks that could not be accomplished in accordance with procedural requirements were not raised to the attention of management in a timely marmer.

The role of the radiation protection supervisors was observed to include coordination of activities with other departments, development and approval of RWPs, pre-job briefings, technician work assignments, document reviews, action item close out, and other staff work.

The supervisors were not observed overseeing the work of technicians or radiation workers in the field. Document reviews appeared to be more of a formality since specific performance standards and expectations regarding execution and documentation of activities (e.g., surveys) are not clearly defined.

The assessors noted the absence of adequate clerical support to the Radiation Protection Department. Many clerical functions including typing, filing, records management, etc. are presently performed by the professional staff. Records management functions typically receive a low priority. This frequently results in several months of filing backlog, and can make document retrieval difficult and cumbersome. Other activities such as typing, directly affected the time available to perform technical and program support tasks.

As part of Station management's response to recent NRC sanctions, all departments were issued a directive to develop standards and expectations. The HP department responded to this directive by soliciting input from all members of the department. The results of the solicitation included items such as improved communication, development of a questioning attitude, promotion of the spirit of cooperation, maintenance of pride in the organization and program, and similar items. Efforts were undenvay to determine how to best incorporate these characteristics into daily HP operations.

The hierarchy of documents associated with the Radiation Protection Department includes corporate policy statements and detailed implementing procedures. Procedures are developed and implemented as either CY specific (RPMs) or corporate documents applicable at more than one NU facility (NUC RPMs). A governing document (e.g. Radiation Protection Manual) for the program which establishes the organization, management, functional responsibilities and authorities, commitments, and methods and controls used to meet these commitments, does not exist.

In general, the procedures reviewed were technically adequate. However, the procedures tend to focus on the specific methods to accomplish tasks, but do not typically provide definition regarding the circumstances and conditions under which the task must be accomplished. In addition, the number of procedure revisions through the years of operation has resulted in procedures that are not well orchestrated. The plant staff that has used the procedures for a number of years can typically cite requirements when asked. However, the assessment team encountered a high degree of difficulty in establishing the location of specific requirements within the procedures. Individuals new to the plant and not as familiar f

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with the flow ofinformation encounter the same problem. The lack of a Radiation Protection Manual added to the difficulties in determining program requirements.

Observations made during this assessment indicated that a number of currect procedures and procedural requirements are not being implemented. In most cases, this was attributed to the current state of the plant. However, these procedures have not been deleted or revised, and decisions to not implement various procedures have been made at the working level.

Management awareness and concurrence is not evident. Examples of procedural issues are defined in the individua' sections of this assessment report.

The assessors attended a meeting of HP department management held for the purpose of discussing and consolidating cpen items within the department. The primary purpose of the meeting was to list and prioritite the items, and identify responsible individuals and item completion dates. The subject items were derived from various sources including, members of the HP staff, NRC inspection reports, ACRs, etc., and involved a wide variety ofitems.

Specifically, items discussed inclu: led short-term issues addressing actual or perceived acute problems, to longer-term issues related to the decontamination and decommissioning of the facility. The reviewers noted the absence of a structured approach to the dispositioning of these items. Each item was discussed separately, and it was not evident that consideration was given to the impact of the combined items on the program, and the resources necessary to complete these tasks. No item completion date extended beyond 30 days, and there was no plan or assignment of responsibility for administration of the " tracking system."

HP self-assessments are addressed in RPM 1.1-3, Work Observations $lealth Physics Department Audits and Technical Support Documcnts, Rev. 6, Dated 3/20/96. This procedure includes requirements to perform weekly work observations and intradepartmental audits, and specifically tasks the HP Manager with identifying the topics or program elements to be evaluated. The last audit performed in accordance with this procedure is identified in the DAR Action Tracking system as HPA-96-01, dated 5/28/96. The Services Group l Supervisor indicated that the self-assessment program has indeed been dormant for about 10 months, and that approximately twelve assessments per year had been conducted when the program was active.

1.3 Conclusions

a. Station management failed to adequately assess the impact of the station changes in mission and organization on the health physics department's ability to implement their program. Therefore, the change was not effectively managed.

b. There is not an up-to-date, documented definition of the role, mission and duties of the health physics organization. There has been a lack of continuity in the Health Physics Manager Position, and a lack of clear, consistent expectations and standards of performance within the Health Physics organization.

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c. Duties, responsibilities, authorities and accountabilities within the orgamzation are not clearly dermed.

d. The current stafling level for the HP organization is inadequate to meet all current procedural commitments in a timely manner.

e. Radiation Protection Supervisors are involved in numerous activities that detract from their ability to observe work and to provide continuous constructive feedback to the work force and their technicians. Identification of problems occurs primarily through the Oversight group, follow-up to an event, or because of NRC inspections.

f. The Health Physics program is a reflection of the historically small, stable plant work force which relied heavily on oral communication and the knowledge, experience, familiarity and personal expectations of individuals. Therefore, programs and procedures, including work planning and scheduling, typically lack sufficient detail to support operations, and provide assurance of continuity of functions in a changing environment.

g. Standards and expectations issues raised by members of the HP organization focused on basic organizational aptitudes. Although valuable and worthy ofimprovement initiatives and continued evaluation, these issues must be supplemented by performance objectives involving productivity improvement or technical issues related to the department's function and responsibilities. The fact that the department staff focused on such basic issues appeared to support the reviewers conclusions that there are basic orgamzational development and human resources shortcomings within the HP Group. Discussions with individuals indicated that they do not fully understand their roles, their position or their importance in the overall structure of the station.

' h. While " things are being done", most of the actions are without unity of purpose or direction and clearly defined objectives.

i. The system being implemented to manage action items in the HP department is essentially an ad hoc in approach. Without a more structured program, there is no assurance that priorities and resource requirements are properly identified, and that future issues will be identified for inclusion into the " action item tracking system" on a continuing basis.

1.4 Recommendations

a. Develop an organization based on functional responsibilities. An example of a typical functional organization is provided in Figure 1. Identify individuals to assume the important roles in the major groups within the department. Identify resources needed to commence the decommissioning project, and establish a transition plan to the new organization.

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b. Prepare a governing document such as a Radiation Protection Plan (RPP) tc describe the organization, roles and responsibilities, program objectives, standards and commitments, and methods and controls that will be employed to assure compliance with those commitments.

c. Reorganize existing procedures to support the methods and commitments established in the RPP, Develop controlling procedures as necessary to coordinate and orchestrate the technical details existing in present procedures.

d. Develop performance objectives for the conduct of business in each functional area.

Performance objectives should emphasize attention to detail and clear documentation.

Expected performance should be reinforced through supervisory oversight and feedback to individuals performing the work. Supervisors should be held accountable for sufficient review to identify and correct problems at the department level.

c. Establish perfonnance measures for indicators that are precursors to events. Performance indicators should be developed for the RWP program, survey program, postings, and other areas whose primary function is prevention of events or control of radiological evolutions.

f. Develop a formal action item tracking system, and identify the individual responsible for implementing this program. This program should include provisions to ensure department priorities and resource requirements are established by the HP Manager.

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2.0 PERSONNEL TRAINING AND QUALIFICATION 2.1 Backeround The assessors reviewed applicable procedures, interviewed members of the health physics staff, including utility and contractor health physics technicians and supervisors to determine the nature of the ongoing training for the health physics staff. Also included in this review were personnel from the radwaste organization supporting the respiratory protection program. This review was limited to training related to requalification / recertification and the dissemination ofinformation related to procedure, policy, and plant operational status changes. This review did not include any aspects of the health physics training for general employees and radiation workers.

2.2 Findings

The assessors noted that the utility Health Physics Technicians had significant experience at CY. Their experience exceeded the requirements of ANSI N18.1/1971.

The following procedures from Volume 1, Chapter 2 of the CY Radiation Protection Manual are applicable to the training of the health physics staff:

RPM 1.2-1, Contractor Health Physics Technician Training, Rev. 3, dated 9/16/94.

RPM 1.2-2, Health Physics and Rad Material Technician Training, Rev. 6, dated 6/8/95.

RPM 1.2-3, Contractor Radmaterial Technician Training, Rev. 2, dated 4/1/96.

RPM 1.2-4, Exempt Personnel Training, Rev. 5, dated 9/2/94.

The Radiation Protection Supervisor (Services) position description contained an accountability to assure that ...all healthphysics supportpersonnel are properly trained and quahfied to perform activities in radiation protection. Training of any type, however, was not listed as a primary duty.

The position description for the Radiation Protection Supervisor (Operations), had a primary responsibility to [m]onitor that alequate technical and regulatory training is providedfor health physics operations by ver; f ying that establishedformal trainingprograms have been implemented. The AccountabSities section included assurance that radiation workers and health physics personnel are properly trained and qualified to perform activities in radiation areas.

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The position description for the Health Physics Manager also had no primary duties related to training, nor did it address the typical managerial responsibility of developing the potential of his direct subordinates. However, procedure RPM 1.2-4 contained provisions for the Health Physics Manager to provide training to subordinate supervisors and managers.

Review of training records for 1995 through April 1997 indicated that the individuals filling the Health Physics Manager position had provided various types of training and information sessions to exempt personnelin the Department. The records for this training did not appear to be complete. Therefore, the full extent of the training that had been provided during the period reviewed could not be determined. From the records available, the asussor noted that the material discussed included technical, industry experience and administrative topics.

Initial technician OJT is documented. The Basis section of RPM 1.2-1 indicated that the conduct of observations in thefield byfirst line snpervisors was to be implemented as an upgrade to the technician training. Discussions with the HP Supervisor (Operations) indicated that this was accomplished through the station's Work Observation Program.

Procedure RPM l.1-3, Work Observation / Health Physics Department Audits and Technical Support Document, Rev. 6, dated 3/20/96, describes this program as implemented in the Health Physics Department. The assessor reviewed copies of completed form ADM 1.1-256 documenting work observations by exempt personnel within the Health Physics Department.

The assessor noted that the procedure states that the completed reports are to be forwarded i to the Self-Assessment Coordinator, a position that no longer exists. In the absence of this position, exempt personnel have been routing the completed reports to the Department's Nuclear Services Technician. Discussions with the Nuclear Services Technician indicated that she simply files the forms when they arrive in her ofTice. Consequently, the assessors i could not locate any work observation records covering the time prior to 1997. The forms contained in the files of the Nuclear Services Technician did not appear to be complete.

There was not a form from each exempt person in the Department for every week in the year to date. Discussions with exempt personnel within the HP Department indicated that they had made the observations. In some cases, they had not completed the reports, or, in other cases had sent the forms to the Nuclear Services Technician, concluding that they must have been lost.

The assessor reviewed forms that summarized observations of technician activities and evaluations of the observed individuals' performance. Where correction of performance was warranted, the observer made such correction. The scope of the activities observed, however, was understandably limited due to the limited work scope at the facility.

Continuing training for HP Operations Technicians consists of approximately two weeks of formal classroom training every year. This training is conducted at Millstone in the spring and fall. All technicians attend each session. Fire Brigade and First aid training are also required Page 7

annually, and are included in this training. There is also a requirement in procedure RPM l.2-1 that "someone," ENSURE that all technicians receive speciali:ed trainingpertinent to specific assigned tasks. The assessor discussed this requirement with various supervisors in the HP Department to determine what this requirement meant and how it was met. These discussions indicated that there was nothing specifically done to address that issue, but that it was believed that the intent was considered in the retraining program.

Training sessions for exempt personnel are conducted routinely at Millstone. Review of training records for 1997 indicated that attendance by exempt personnel was spotty. Some attended regularly, some not at all. Attendance was typically based on time availability related to station workload. In addition, since all training is conducted at Millstone (usually around lunchtime) station personnel stated that they believed they lost too much time attending the training for the value received. Exempt personnel have attended various seminars and professional meetings to supplement work activities and maintain knowledge state-of-the-art.

The assessors reviewed the provisions for the routine dissemination ofinformation to HP technicians regarding changes to procedures, station activities and other items of significance to the day-to-day operations and job coverages. Discussions with HP supervision indicated that this type of information is routinely disseminated during the daily 7:00 a.m. health physics meeting. Discussions with responsible individuals indicated that, while no formal meeting minutes are kept, they do list who attended and very generally include the subjects discussed. Typically, information contained in the supervisor's dayplanner is used as the basis for the meeting. Other means to disseminate information included " formal" memoranda (which receive a Department tracking number), " informal" memoranda, e-mail, and document acknowledgement sheets (read and sign).

! To determine whether the methods being used were effective, the assessors interviewed HP 1

technicians concerning the HP Department's recently implemented interim measures to control the release of material from the RCA. The assessors determined the HP technicians interviewed were aware of the measures. There was, however, no documentation supporting acknowledgment of understanding by all HP technicians (including contract technicians). In particular, the acessors noted that there was no record that technicians read and understood memoranda or e-mails containing updated information. Also, there were not clear provisions to provide the information to technicians who may have missed daily meetings due to illness, vacation, shift-work, etc. Training on the release of materials from the RCA had just been initiated and included contractor technicians, although discussion indicated that contractor technicians were not always included in training sessions.

Page 8

The assessors also noted that, there was no formal, documented method for consistently disseminating information to the general plant staff regarding health physics changes that may impact the general staff.

The assessors also reviewed the training of other individuals supporting the Health Physics Department functions for the respiratory protection program fit testing and respirator repair and maintenance. The assessors noted that the individuals performing fit testing were trained on use of the PortaCount system by a vendor representative. This initial training was about 5 years ago.

Repair of respirators is accomplished by an individuals (Radioactive Material Handler) qualified through training by the respirator vendor and through on the job experience.

Discussion with the responsible individuals indicated that the last training was about 5 years ago, and that some refresher training would be helpful to maintain proficiency.

2.3 Conclusions

a. Responsibilities for training oversight and records maintenance within the Health Physics Department are not clearly defined.

b. Selection and qualification criteria for contractor technicians in responsible positions (Senior Health Physics Technicians and Contractor Supervisors) are clearly and unambiguously defined and consistent with the intent of ANSI /N18.1 - 1971.

c. The CY HP Technician staff satisfies the qualification requirements established in the plant technical specifications.

d. The CY HP Department does not have routine involvement in the development of the retraining curriculum ofits Technicians.

e. Exempt personnel have not regularly attended exempt personnel training as specified in procedure RPM 1.2-4. This was due, in part, to the location of the training being at Millstone in conjunction with the CY station workload. The applicability of the exempt personnel training as historically presented may be oflittle practical value to the CY plant's HP exempt staff personnel as the CY plant enters the decommissioning phase.

f. The dissemination of information pertaining to changes to the HP program and procedures is inconsistent in method and detail, and fails to ensure that technicians receive, understand, and properly apply the information as intended.

Page 9 -

i

g. Individuals performing respirator fit testing and respirator repsir and maintenance do not have a defined program for retraining that ensures maintenance of proficiency.

2.4 Recommendations

a. Define responsibilities for general training oversight and intra-departmental training, '

including planning, conduct and records maintenance. (See recommendation 1.4.a.)

b. Complete the training and dissemination ofinformation to all Health Physics technicians (including contractor technicians) on the recent event involving the unintentional release of contaminated material from the RCA. Also, include a description of the program changes instituted to provide additional control of material leaving the RCA.

c. Conduct the exempt personnel training specified in RPM 1.2-4 at the CY facility. Orient this training to focus specifically to the unique HP problems and aspects of the decommissioning environment at CY. This training should also continually reinforce the CY site standards and expectations for the HP Program during the decommissioning operation.

, d. Develop a program for promptly and effectively disseminating information to the HP staff I regarding program, policy and procedure changes. This program must ensure that all performance expectations are clearly presented, understood and acknowledged by technicians prior to implementation. Establish single point responsibility for determining the method (e.g., memo, formal training, read and sign, morning meeting, etc.,) to be used based on the significance and complexity of the change.

e. Develop provisions to periodically review the HP technician retraining material presented by the Millstone Training Department to verify that plant specific topics are addressed l and that these topics are consistent with the CY's expectations and plant conditions.

f. Defme a scope and nature of training for individuals supporting the respiratory protection program that will maintain their proficiency and update their knowledge of industry I changes.

Page 10 5

3.0 EXPOSURE MONITORING 3.1 External Exposure Monitoring 3.1.1 Dosimetry Prorr1H! -

3.1.1.1 Backtrg. gad The assessment team reviewed the dosimetry program in place at CY. The review included equipment, facilities, calibrations, procedures, quality assurance, and associated records. The dosimetry program was evaluated against the applicable criteria of 10CFR20. The primary requirements for the dosimetry program are specified in Subpart C and in 20.1501 (c). INPO 91-014, Guidelinesfor RadiologicalProtection at Nuclear Power Stations, Rev.

1, dated October 1995, and the September 1996 NVLAP report, On-Site Assessment Report, Northeast Utilities Service Company, dated September 16 19,1996, were used as key references during this review.

3.1.1.2 Findings

a. General CY contracts with the Northeast Utilities Dosimetry Laboratory for primary dosimetry, including processing. Thermoluminescent dosimeters (TLDs) are used to measure occupational exposure to ionizing radiation under 10 CFR 20.1201 in terms of deep- and shallow-dose equivalent.

The Dosimetry Laboratory uses the Harshaw/Bicron Model 8800 Whole-Body TLD System. This is a 4-chip TLD, capable of measuring gamma, beta, and neutron exposures. The laboratory processes finger ring dosimeters using Teledyne LiF discs on a Panasonic UD-513 A TLD disc reader. Calibrations and processing of TLDs are performed in accordance with procedures contained in the Northeast Utilities System Radiological Assessment Branch Procedures Manual.

The Eberline Model DD 300 electronic dosimeter (ED) is used as the secondary dosimeter. Eberline Fastrack Readers are used to process EDs.

CY maintains the electronic dosimetry system, which has been used since mid-first quarter 1995. Pocket ion chambers were used prior to establishing the ED system. Calibration of EDs is done by CY using the NU corporate procedure, NUC RPM 4.6.2, Eberline Electronic Dosimeter Calibration, dated 3/8/96.

Page 11

b. Issue and Us Beginning in January 1995, TLD issue was on a 6-month basis. CY returned to quarterly issue of TLDs in the first quarter of 1997. About 1800 personnel were badged in 1996, and 500 in the first quarter of 1997.

Personnel maintain possession of their assigned TLD when they leave the site. The HP Services Group Supervisor stated that this has been the practice for about one year. The practice resulted from NU QAS Surveillance Implementation Plan No. CY-P-96-030, Exposure Control, closed on 3/26/96. This report concluded that the area of" dosimetry controls to prevent issue /use of dosimetry by incorrect personnel" was not in compliance. The report stated:

At this tim 3 no controls exist, but complete control is scheduled to be implemented in April 1996 by giving to each person their dosimetry and making them personally responsiblefor it. . . At the present time, all TLDs are located / stored in locations near the entrance to the RCA. There is no control over personnel as to which TLD they take. .

Errors have occurred in the past, and at this time positive control is not being venfied. HP supervision stated plans are being implemented to provide positive control by having personnel take their dosimetry with them and selfstore them. This self-storage isplannedfor April 1996, andshould alleviate problemsfrom recurring in this area.

(!AS anticipates that self storage of dosimetry will provide positive control over TLDs, and reduce errors in this important area.

The September 1996, NVLAP On-Site Assessment Report for the Dosimetry Laboratory stated: lt]he practice of allowing individuals to take their TLDs home is undesirable from a quality of measurement standpoint due to the uncertainty introduced.

The HP Services Group Supervisor indicated that plans are under way to once again retain all TLDs onsite, effective July 1,1997.

TLD issue was recently moved from the HP lunch room area inside the Protected Area to the Dosimetry Records area in the PAP building, outside the Protected Area.

c. Procedures Procedures governing the dosimetry program for external exposure are both station (RPMs) and system (NUC RPM 1) in origin. Specific issue requirements are in: RPM 1.3-1, External Whole Body Dosimetry Issue &

Page 12

Pull, Rev.15, dated 7/29/96; RPM 1.3-2, Extremity Dosimetry Issue, Rev. 6, dated 6/7/96; RPM 1.3-4, Multi-badge Dosimetry Requirements, Rev. 3, dated 12/12/95, RPM 1.3-7, Visitor Dosimetry Issue, Rev. 9, dated 7/23/96; and RPM 1.3-9, Use ofPREMfor Dosimetry Issue, Pull t and Assessment ofExposure, Rev. ORIG, dated 12/27/94. Investigation i requirements are in: RPM 1.3-11, Lost Dosimetry, Rev. 4, dated 2/17/96; i RPM l.3-12, Questionable Secondary Dosimetry (Pocket Ion Chamber-Electronic Dosimeter), Rev. 5, dated 3/20/96; and RPM 1.3-13, Dosimetry Discrepancies, Rev. 5, dated 2/17/96. Calculations for non-routine requirements are in RPM 1.3-14, Varskin Dose Calculation, Rev.  !

3, dated 12/12/95 and in RPM 1.3-15, ExternalDose Calculations, Rev.

3, dated 12/8/95. Implementing requirements under 10 CFR 20.1206 are in RPM 1.3-17, Planned Special Exposure, Rev.1, dated 12/12/95. 1 Electronic dosimetry source check and calibration requirements are in '

NUC RPM 4.7.3, Electronic Dosimetry Source Checks, Rev. O, Dated 2/15/% and in NUC RPM 4.6.2, Eberline Electronic Dosimeter Calibration, dated 3/8/96. The CY requirements for QA testing of TLDs are ir. NUC RPM 1.7.1, TLD Performance Testing, Rev.1, dated 1/29/97. ,

Requirements for seeking and approving increases to administrative -

exposure levels are in NUC RPM 5.1.4, Annual Occupational Exposu. e Control and Increased Radiation Exposure Approval, Rev. O, dated 10/31/95.

d. Records ardRecorts Th Nuclear Servius Technician responsible for maintaining dosimetry rec.srds, is performing duties previously assigned to two positions: the HP Ad'nin Technician and the Dosimetry Records Technician. These positions were combined when the individual filling the HP Admin Technician position left. The auditors noted that filing ofindividual exposure records

, was heavily backlogged. The stack of records to be filed is several inches tall .nd dates from January 1977. Records awaiting dispositioning to Nuclear Documents are in several stacks; each stack is a few feet tall.

There is a computerized exposure records system, PREM, for automated exposure records use. It appears to be robust in its capabilities and

! satisfactory for its intended purpose.

e. TLD Capabilities. Processinn and Reoortine The Harshaw/Bicron TLD and finger dosimetry system capabilities are 4

_ summarized in Northeast Utilities Personnel Dosimetry Services Manual, 1 Rev. 4, dated December 1995. j I

Page 13  ;

1 y + e mm . -- ,o - - - . - . , .

1 i

b A September 1996 NVLAP report, On-Site Assessment Report, Northeast

Utilit/es Service Company, dated September 16-19, 19 %, included the following summary assessment of capabilities

Although this assesanent report identiped a number ofitemsfor impronment of the dosimetry processing system, no items were identiped that would indicate that the doses reported by the Northeast Utilities Dosimetry Laboratory do not meet the '

i requisite quality ofNVLAP Accreditation.

i The Dosimetry Laboratory passed each category tested (I, II, IIIB, IV, VB, and VI through IX) in its most recent NVLAP Personnel Dosimetry Performance Test, conducted in the first quarter 1995.

The 1996 NVLAP report identified four deficiencies requiring a written response to NIST and six recommendations with no written response required. The Laboratory responded in writing with their action plan for addressing all of the deficiencies and recommendations within the required  ;

30 days. The Laboratory has not received the final evaluation from  !

NVLAP for the 1996 on-site assessment. The final evaluation, with a statement as to accreditation status, will be provided after NIST evaluates the report, the Laboratory's responses, and the results of any proficiency testing. Items from the assessment and identified here convey the opinion ,

of the assessor as a single representative ofNVLAP. )

i i i Theihntified deficiencies were:

l. The quality system should be expanded to include use of blind audit dosimeters; l 2. The method and frequency of determination of ECCs may be

[ madequate; i

4

3. The technical basis for determining control values for Millstone Plant and Connecticut Yr.nkee badges is inadequate and the control values used an not calculated in accordance with the technical document; and 4

4. The program for control of the TLDs is inadequate.

1 The Laboratory's written commitments in response' to the deficiencies l nave all been completed, with the exception of the final part of the action plan to address the deficiency regarding Element Correction Coefficients (ECCs). For that, the Laboratory committed to modify the applicable procedure by 5/31/97 to provide a method to ensure that the effects of Page 14

aging, ficid Adling and repetitive reading of field TLDs are properly

, accounted for.

The Lab completed the committed preliminary assessments by the specified date and has initiated the redetermination of ECCs for all '

dosimeter cards. By early April, new ECCs for approximately 10,000 of the 27,000 card population had been determined. All TLDs issued to CY on 4/1/97 have the new ECCs. The Laboratory did not commit to a 4

completion date for the redcterminations.

)-

Recommendation #6 was to conduct intercomparison testing to l

demonstrate the backup capability in case of catastrophic loss of the l

'.' Dosimetry Laboratory. Duke Power and the Northeast Utilities Dosimetry Laboratory use the same model Harshaw TLD system. A formal agreement exists between Duke Power and the Northeast Utilities Dosimetry Laboratory to provide mutual backup processing capability.

The committed intercomparison performance test was completed ,

satisfactorily before the specified date.

While not stated as a deficiency or recommendation, the NVLAP report j j described, at length, the recent history of changes in the organizational and management structure, and noted a sense of uncertainty about the permanent nature of the new structure and staffing. The report concluded stating: [ljn summary, the current organizational staffing and i structure has not been in place long enough to adequately evaluate its ability to make improvements and ensure an independent, quality operation, t

The report addressed the Laboratory's quality system succinctly and favorably, stating: [t]he Quality Systemfor the Dosimetry Laboratory is  ;

i very good Ihe Quality Manual is well conceived and provides an excellent overview of the qualityprogram. t i f. Secondary Dosimetry Prior to 1996, CY used PICS as the secondary docimetiy. There are i procedures addressing issuance and use of electronic dosimeters (ED).

4

~ Procedures do not, however, specifically address the use of multiple i dosimeters in the case of welding or use of impact tools which may  ;

adversely affect ED performance. In such cases, workers are provided with both a PIC (SRD) and ED. i Procedures NUC RPM 4.6.2, Eberline Electronic Dosimeter Calibration, Rev. O, dated 3/8/96, addresses calibration of the Eberline DD-300 used at CY. 1 Page 15 i

,w p -, 3 y-_ ~

...--e r -

..,.r ,_., --

B i

Calibration of EDs is performed by two technicians, one with 20+ years of experience and the other with 18+ years of experience, all at the HNP performing the calibration operation. ,

PICS are used primarily in emergency kits and for specialized jobs such as welding, using electric impact guns and similar operations where the ED is known to be adversely affected. ' In such cases, workers are issued a PIC 1 and an ED.

g. TLD/EDIntercomparisons F t

CY procedure, RPM 1.3-13, Dosimetry Discrepancies, provides the criterion for an evaluation of external exposure and a dose assessment  ;

when the accuracy or reliability of dosimetry information is suspect. The criterion is derived from INPO Good Practice 82-001-EPN-03, j Comparison ofDosimetry Results, which specifies that a dose assessment i

should be performed if the TLD and secondary dosimetry results differ by i 1 more than 100 mrem and t25%. 1 I

The CY PREM system has programmed provisions for flagging and j reporting any intercomparison dosimetry data meeting the above criterion

and thereby requiring an evaluation and dose assessment. The assessor i reviewed PREM report (PREM report ID DDWACH00), Oficial vs.

Unofficial Dose Comparison, for two time periods covering the first  ;

quarter of 1997 and first half of 1996. Based on the dosimetry data  :

reported, no dose assessments were needed. PREM properly reported

this analysis. 1 i

Discussion with the individual responsible for preparing the Official vs.  ;

UnofficialDose Comparison report indicated that the report is run at the '

end of each badging period and is triggered upon receipt of the TLD results. Any results requiring a dose assessment are forwarded to the Health Physicist for evaluation.

The Millstone Radiological Engineering group conducted a special  !

TLD/ Secondary dosimetry intercomparison covering the period 1/1/% I through 6/30/96. This evaluation was to focus on Millstone dosimetry, however, CY dosimetry results were included as well. The intercomparisons were made using the criterion of Millstone Procedure 1.3.7, Lost, Of-Scale or Questionable Dosimetry, (TLD and secondary dosimetry results differ by more than 100 mrem and i25%). This criterion was the same as that specified in CY procedure RPM L3-13.

The basis for the Millstone criterion, however, was incorrectly stated to be INPO 91-014, Guidelinesfor Radiological Protection at Nuclear Power ,

I i

Page 16 l

Stations. The criterion as actually contained in Millstone procedure 1.3.7, was, however, consistent with INPO Good Practice 82-001-EPN-03. The INPO 91-014 criterion states, "A comparison of TLD and sel#-reading dosimeters for the same time period and body location shows a significant difference in measured dose (e.g., TLD or self-reading dosimeter dose exceeds 100 mrem and self reading dosimeter reading (s) differs by more than .25% from the TLD).

l Based on the CY criterion (INPO Good Practice 82-001-EPN-03), the report indicated that, at CY, 986 TLDs were processed in the 6-month period and that there were no dose discrepancies requiring a dose assessment. This result was consistent with the PREM generated report discussed above.

i The assessors noted that the special TLD/ Secondary dosimetry 1 intercomparison also compared the TLD/ED data with the guidance of INPO 91-014. If these criteria were applied, 8 dose assessments would have been necessary. This special study also analyzed the bias of the  ;

TLD/ED intercomparison data. This analysis indicated that CY experienced a negative bias (TLD dose exceeding the ED dose) since the adoption of the ED as the secondary dosimeter. For the second half of 1995 (using PICS as the secondary dosimeter) the bias was +15.1%.

Since the change in 1996 to using the ED as the secondary dosimetry, the bias has shifted to -8.1%.

The assessor noted that the CY's evaluations of TLD/ED intercomparison i data are limited to resolving dose discrepancies that fall within the criteria of procedure RPM 1.3-13. There does not appear to be a comprehensive  ;

evaluation of performance, as reflected by tracking and trending the data  !

I bias.

h. Ouality Assurance Procedures are in place for CY to periodically test the Laboratory's TLD

processing capability.

I l

3.1.1.3 Conclusions

, a. The practice of having personnel keep their TLDs at all times adds uncertainty to the determination of occupational exposure recorded by the 4 TLD.

b. The relocation of dosimetry issue into the PAP was a positive move in that new personnel and visitors no longer must enter the Protected Area to fill out the required Dosimetry Issue forms.

9 Page 17

4 1 >

l

c. Filing of exposure records is not being kept up to date. While there is an individual assigned to this responsibility, the individual's workload is

excessive,

d. PREM, the dedicated exposure record system, appears to adequately  ;

address exposure records requirements.

e. An external radiation dosimetry system suitable for the radiation exposure types and levels anticipated during routine or non-routine work operations is in place. Adequate facilities exist for reading, processing, storing and

calibrating all types of dosimeters in use. The personnel available to  ;

perform the required dosimetry functions have adequate knowledge to l perform the normal duties as well as to recognize unusual events that may require special interpretations or evaluations.

l

' f. Extremity dosimeters supplied by the dosimetry processing laboratory and  !

applicable RPM procedures are suitable to measure or calculate extremity l exposures. The capability to determine skin exposure by measurement or j modeling is present via RPM 1.3-14, Varskin Dose Calculations, Rev. 3, 1 dated 12/8/95. Techniques suitable to measure neutron exposures are in  !

place. Techniques suitable to measure photon energies of greater than 3 MeV and less than 80 kev are in place.

g. Alternate offsite facilities for processing TLDs have been identified. A memorandum of Agreement exists and the next phase of the evaluation will be completed soon.

h. The conduct of routine TLD/ secondary dosimetry intercomparisons is not formalized. ,

i

> 3.1.1.4 Recommendations

a. Do not permit personnel to remove their TLD from the site. This will require storage of TLDs in a dedicated and secure area, including space 1

for co-location of control TLDs. Storage in individual lockers should not be permitted. Coordinate with the Northeast Utilities Dosimetry Laboratory so that all technical considerations addressed in the 1996 i NVLAP report for control TLDs and appropriate dosimetry processing are addressed.

b. Evaluate the functional responsibilities and resource requirements of the on-site dosimetry program This evaluation should be included in the Page 18

4 programmatic review of functional responsibilities and resource requirements as discussed in Section 1.

c. Perform a technical evaluation of the revised ECCs, including an assessment of the expected effects of the revised ECCs on doses of record which were recorded before the new ECCs were appied. t These expectations should be expressed in quantitative and qualitative (i.e.,

conservative /non-conservative) terms. An appropriate document for such L an evaluation might be the CY-HP-00 series of Technical Support

Documents, which are cited as a technical basis for Requisites in many procedures.

d. Formalize the TLD/ secondary dosimetry intercomparisons process to the point that it is routinely scheduled (automatically triggered), reports are l disseminated, evaluation methods are specified (to include tracking the TLD/ secondary dosimetry intercomparison bias).

3.1.2 Exposure Review (Dose Assessment)

, 3.1.2.1 Backaround  ;

)

The assessment team reviewed exposure records and management reviews of

, exposure records. These reviews were performed to determine both the

, regulatory adequacy and the archival quality of the records, and to determine the degree of management commitment to the quality of these records. The  ;

results of the ALARA program are reflected in the individual exposure

records and in summaries of those records. The individual exposure records are permanent records; they provide a historical accounting of exposures of record. A key element of the review was to assess the degree to which these records may serve as stand-alone, defensible documents.

l 3.1.2.2 Findines i a. Discrecancy Reoorts The assessors reviewed dosimetry discrepancy reports for 1996 and 1997.

The HP Services Group Supervisor maintains a personal spreadsheet of these dosimetry discrepancy investigations, and a subject file is maintained

, at HP Records, but no database is maintained (e.g, in PREM) of completed investigations. According to the spreadsheets, there was one TLD/PIC investigation completed in 1995, 3 TLD/ED investigations in 1996, and none to date in 1997. According to the spreadsheets, there were 46 Lost Dosimetry investigations conducted in 1996, and 1 to date in 1997.

Page 19 l

The assessor reviewed three TLD/ED discrepancy reports in individual exposure records to verify completeness, adequacy, and their utility and s

defensibility in the event of any historical assessment performed in the i future. l 1

i Case 1. TLD number 118871 was worn from 8/16 to 8/26/%. The l discrepancy report indicated 16 ED entries for a total of 668 mrerm, while the TLD read a total of 943 mrem. The TLD was sent to the

, Dosimetry Laboratory for verification, however, no record could be found at CY attesting to results of this verification. In the Comment ,

Block, Other was checked and the comment, [f]aulty ED -pulledfrom usefor evaluation, was entered. The TLD dose value of 943 mrem was  !

entered as dose of record. Offsite was printed in Worker  !

Acknowledgement signature block. The report was in the individuals  !

exposure record.

A second dosimetry discrepancy report, for the same individual and for the same TLD, was found in the stack of records awaiting filing. This second report, generated on 2/24/97 and approved by the HPM on 2/27/97, listed 57 (not 16) ED entries. It also differed from the first >

report in a number of key aspects. In the Comment Block, Multiple ED Readings was checked. The comments on the report were: Worker .

performed removal of insulation' lagging, making numerous entries.  !

Higher TLD restdt could have resultedfrom twt wearing TLD in close l i

proximity to ED. Co-workers hadsimilar ED to TLD relationship Case 2 TLD 148480 was worn from 6/11/96 to 11/20/96. The ED entry read (38) totaled 21 and the TLD read 221. Although the TLD .

was sent to the Dosimetry Lab for verification, there was no record at CY to substantiate the results. No Comment block is checked. The Supervisor stated that at least one block should be checked. The

comments on the repon were, TLD was not representative of i

areas / dose rates worked Discussion with worker indicated she never entered any areas or did anything that couldgive her this exposure (by TLD). ED read was appropriate. The value of 21 was entered as the permanent exposure, based on ED. The word Offsite was entered in the worker signature block. The repon was generated on 2/24/97 and approved by the Health Physics Manager on 2/27/97. The HP supervisor stated that several things were done for this investigation.

All of the access control events and pertinent RWPs were examined.

There was a determination of whom the individual's co-workers were, and their doses were compared with the individual in question. None of the specifics of the investigation were entered in the Comments section of the report. As a stand-alone document in the permanent record, the report did not indicate the depth to which the investigation was conducted.

Page 20

l l

[

t Case 3. TLD number 166863 was worn from 8/8 to 8/22/96. The individual's ED dose totaled 584 for a total of 56 entries and the TLD i read 450. The TLD was sent to Dosimetry Lab for verification, but there was no record at CY attesting to results. In the comment block,

. Multiple ED Readings is checked. The HP supervisor stated that the block "Within acceptance criteria of RPM 1.3-13" should have been ,

. checked instead. No written comments were entered. The TLD 3 i reading was entered as dose of record and "Offsite" was entered in the l

worker signature block. The report was generated on 10/24/96 and j approved by Health Physics Manager on 10/30/%.

j The 1995 TLD verification request duments reviewed in Exposure I Records all contained written indications from the Dosimetry Lab of the f verification results. Similar TLD verification request documents for 1996 I are in Exposure Records. None of these 1996 requests contain any I notation as to the results. In addition, not all of the TLDs listed on the 1996 requests for TLD verification were the subject of the previously discussed discrepancy reports.

The reasons for these other TLD verification requests was indeterminate from the records available for

review.

i'

(

The Lost Dosimetry Report, Attachment A to RPM 1.3-11, contains 4 )

lines to enter any comments. The assessor reviewed a report filed in an l individual's exposure reports for TLD number 140099, issued on 8/5/96, ,

and lost on 9/5/96. The ED Readings Since Issue of TLD block had one '

f value, 271, entered, lined through and initialed, and a lower value (170)  !

entered. The same entry, line through and initialed, and lower value, was i entered in the block " Accumulated ED Prior to TLD Loss (sic) mrem Entered as Permanent Record." The comment section stated: Lost TLD l while inside ofcontainment, looked in PCs but was unable tofind. Used ersctronic dosimeter reading for calc. Among the applicable recommendations ofINPO 91-014 for inclusion in such a worker dose l assessment is a determination of the dose to the individual based on dose received by coworkers or calculating a dose based on occupancy time and  !

dose rates in the work area. According to RPM 1.3-11, such evaluations l

are not done if only the TLD is lost while working on an RWP. l i

l

b. Unarades to Administrative Exoosure Levels I

1 1 Requirements for seeking and approving increases to administrative exposure levels are in the NU Common Procedure, NUC RPM 5.1.4, Annual Occupational Exposure Control and Increased Radiation Exposure Approml, Rev. O, dated 10/31/95. This Common Procedure replaced RPM 1.3-6,IncreasedExposure Authorization (Upgrades), Rev.

l Page 21

l Erposure Approval, Rev. O, dated 10/31/95. This Common Procedure replaced RPM l.3-6,increasedExposure Authorization (Upgrades), Rev. 1

10, dated 11/11/94. Although it is one page longer, NUC RPM 5.1.4 l contains less detail and fewer requirements or guidelines relative to l ALARA considerations than were contained in RPM 1.3-6. Examples of  ;

i such items contained in RPM 1.3.6 and not in NUC RPM 5.1.4 are:

statements of corporate annual exposure goals for contractor and NU

' system personnel with applicable signature blocks on the request forms; reference to NU HP Standard Practice 2.1, Administrative Dose Controls, which establishes corporate administrative limits in terms of ' goals' and

~

' guidelines;' the stated restriction to approve increases above 2000 mrem "in increments not greater than 500 mrem."

The superceded procedure required the requesting supervisor to enter definitive statements as to either "why the individual is uniquely qualified to perform the job," or "why the individual exposure limit needs to be extended." Currently, the requesting supervisor need only check a box with one of the following pre-printed entries: job expertise; equalization of exposure; job completion; or no other personnel available. The HP Supervisor-Services stated that her Group was to gather more information now about the nature of the planned work to evaluate the request, and that she and her counterpart at Millstone have both questioned the

meaning of particular requirements or statements in NUC RPM 5.1.4.

No datsase is maintained (e.g, in PREM) of completed upgrade requests,

, nor was any other summary file or document containing this information identified i

3.1.2.3 Conclusions

a. Dosimetry discrepancy reports lack investigation details and cross-referencing ofinvestigation results. While details are retrievable in the short term, retrievability diminishes rapidly over time due to the sparse documentation. Discrepancy reports, entered into individual exposure

, records, should be able to stand future tests of defensibility and utility as either stand-alone documents or with suitable cross-referencing.

b. The process for increasing administrative exposure levels does not sufficiently challenge either the requesting supervisor or the approving manager (s). This is evidenced by elimination of the previous requirements l to (1) enter some definitive justification statement (checking a box with a pre-printed phrase is now permitted), and (2) answer questions regarding effects on corporate exposure goals. The process does not provide written guidance and restrictions on prudent incremental increases.

1 Page 22 l

l 3.1.2.4 Recommendations I

a. Develop standards for determining dose assignments from means other l

than normal TLD readings. The standards should include a means to j establish the validity of the value chosen through comparisons with the l ED reading, stay-time calculations, known exposures of other personnel, quality check of the TLD, etc. If this information is not used for the final resolution, comments regarding the rationale for excluding the information should be fully documented. The final resolution and the actual dose j assigned should be signed by the individual whose dose is affected.

Approval of the completed evaluation form should be by the highest level

within the Health Physics Department not involved in the evaluation. ,

Consideration should be given to having the Health Physics Manager give l

, final approval to the record. i i

b. Modify the process of requesting and granting incrccses in administrative j exposure limits. The requests should require detailed justification by the

management of the requesting organization. Include provisions on the request form to require a higher level of line management approval for

each increment of 500 mrem exposure increase requested. A similar increases in the level of Health Physics Department management approval for increases in the increment of additional exposure requested should be instituted.

c. Develop a database of completed upgrade requests and approvals of administrative dose limits.

3.2 Internal Ennosure Monitorine I

3.2.1 Dosimetry Proeram '

l l

3.2.1.1 Backeround '

l

, The assessment team reviewed the internal dosimetry program, to included equipment, facilities, calibrations, procedures, quality assurance, and associated records. The internal dosimetry progam was evaluated against ,

the applicable criteria of 10CFR20. The prii. - y requirements and l

guidance for the dosimetry program are specified in 10CFR20, Subpart C and in 20.1502 (b) and INPO 91-014, Guidelines for Radiological

, Protection at Nuclear Power Stations, Rev.1, dated October 1995.

l l

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l l

'3.2.1.2 Findines

a. General CY maintains two whole body counters on-site within the Emergency i Operations Facility. The stand-up unit (Canberra Model 2250 FASTSCAN) is used for routine analysis. The shadow-shield bed (Canberra Model 2260 ACCUSCAN) is available for positional counting, e.g., following decontamination, and for " investigational" counting following a positive screening count. Both units employ NaI detectors

coupled to a multichannel analyzer. For additional bioassay analyses, CY

maintains a contract with Teledyne Brown Engineering. This contract includes terms for urinalysis, fecal analysis, and blood analysis.

b. Procedures Several procedures govern the dosimetry program for internal exposure.

l The methods and frequency of analyzing blind spiked samples from external laboratories and from other departments are specified in procedure RPM 1.1-8, Split Sample Program, Rev. 2, dated 6/28/96.

The conditions requiring routine whole body counting and exemptions are

specifled in RPM 1.4-1, Routine Whole Body Counting (WBC), Rev. 5, dated 9/1/95, and RPM 1.4-2, Whole Body Count Exemptions, Rev. 3, dated 7/12/96. Requirements for non-routine whole body counting, including those designed to evaluate effectiveness of the air sampling and 4

respiratory protection programs are in RPM 1.4-3, Non-routine Whole Body Counting (WBC) Requirements, Rev. 4, dated 2/28/97.

Requirements for in-vitro sample collection and shipment are in procedure RPM 1.4-4, Bioassay Sampling, Rev. 3, dated 1/1/94 and RPM 1.4-5, '

Bioassay Shipment, Rev. 5, dated 3/29/96. Requirements for review of completed in-vivo and in-vitro analyses are in RPM 1.4-6, Whole Body Count Reviews, Rev. 3, dated 1/1/94 and RPM 1.4-7, Ercreta Bioassay Analysis Review, Rev. 5, dated 9/8/94. Requirements for entering, retrieving or modifying unofficial and official exposure (including internal) into the computerized exposure record database are in RPM 1.4-8, Use of the PREM Dosimetry Data Management Subsystem, Rev. 2, dated 12/6/96. Methods to calculate DAC-hour equivalents and to calculate committed effective dose equivalents from DAC-hour equivalents are specified in RPM 1.4-9, InternalDose Assessment, Rev. 4, dated 11/2/94.

Methods to calculate organ-specific dose equivalents are specified in RPM 1.4-10, Organ Specific Dose Calculations, Rev. O, dated 1/1/94.

Page 24

Specific requirements for operators of the whole body counting equipment, including specifications for calibrations, quality assurance, type i

of count performed, and for action points and actions to be taken based on results are in: RPM 4 31, Whole Body Counting System Energy l Calibration, Rev. 5, dated 8/6/96; RPM 4.3-2, Nie Body Counting '

System Eficiency Calibration, Rev. 4, dated 816/%; RPM 4.3-3, Whole .

Body Counting System Baseline Activity Determination,^ Rev. 4, dated 1

8/6/96; RPM 4.3-4, Whole Body Counting System Daily Routine, Rev. 4, i dated 8/6/%; RPM 4.3-5, Whole Body Counting (WBC), Rev. 5, dated 8/16/%; RPM 4.3-6, Whole Body Counting System Monthly Checks, Rev. '

i 4, dated 4/9/96; RPM 4.3-7, Whole Body Counting System Blind Samples l Checks, Rev. 4, dated 8/6/96; RPM 4.3-8, Whole Body Counting System l Quality Assurance, Rev. 3, dated 8/30/94; RPM 4.3-9, Whole Body Counting System Gain Adjustment, Rev. 4, dated 8/6/96; and RPM 4.3-10, Whole Body Counting System Tape Backup, Rev. 4, dsted 8/6/96.

, Procedure RPM 1.4-10, Section 3.1, Assessment -In-Vivo /In-Vitro, lists

. the steps to calculate organ-specific committed dose equivalents from l

bioassay data. The steps in Section 3.1 follow the example provided in the Appendix to NRC Regulatory Guide 8.34, Monitoring Criteria and Methods to Calculate OccupationalRadiation Doses, July 1992. That

example, however, is specific to an intake via inhalation. Neither the RPM 1,4-10 organ dose assessment sheet, Attachment A, nor Section 3.1 instmetions require the entering of mode ofintake. Although step 3.1.3 requires recording of classification D, W, or Y (which apply to inhalation i but do not apply to ingestion), there is no statement in RPM 1.4-10 which would indicate that it is intended solely for use in an inhalation exposure. i Step 3.1.5 refers appropriately to Federal Guidance Report No. I1, l

Limiting Values ofRadionuclide Intake and Air Concentration and Dose Conversion Factors for Inhalation, Submersion, and Ingestion, September 1988. However, step 3.1.5 requires exclusive use of FGR 11 i Table 2.1, Erposure-to-Dose Conversion Factorsfor Inhalation, without l consideration of the mode ofintake. FGR 11 Table 2.1 is appropriate for l intake by inhalation (which is the mode ofintake in the Regulatory Guide 8.34 example), bu

is inappropriate for intake by ingestion. For the case  ;

ofintake by ingestion, FGR 11 Table 2.2, Erposure-to-Dose Conversion ,

Factorsfor Ingestion, applies. Paragraph 5.1 of Regulatory Guide 8.34 l l

' discusses the acceptable use of FGR 11 Tables 2.1 and 2.2, and notes that l the dose conversion factor is taken "from Table 2.1 or Table 2.2 in l Federal Guidance Report No. I1." i i

Attachment A of RPM 1,4-10 unnecessarily contains a column headed

" Remainder" under the Organ-Specific Committed Dose Equivalent section. Regulatory Guide 8.34 states in the Appendix example, "The dose factor for the ' remainder' in Federal Guidance Report No.11 is not s

Page 25 i

h 4

~

listed here or used to calculate organ-specific committed dose equivalents because it does not represent a dose to a particular individual organ."

To arrive at a " committed dose equivalent (in units of rem) to the maximally exposed organ," Section 3.2 ofRPM 1.4-10:

1. Determines " uncovered" DAC-hours (year-to-date DAC-hours which j have not been assessed by bioassay);

I

2. Multiplies that value by 2.5 mrem /DAC-hour, and i

3. Adds the calculated values to the previously assessed organ-specific CDEsin Attachment A.

, Step 3.3.1 requires this resulting calculated dose to be entered into 4

PREM.

i

The assessor noted that this represents a conservative approach in determining committed dose equivalent to the maximally exposed organ (which is not included in the Regulatory Guide 8.34 Appendix Example).

The conversion for the stochastic DAC to committed e.gective dose i equivalent is 2.5 mrem /DAC-hours. The calculation in step 3.2.3 is intended to calculate committed dose equivalent so the factor that should I be used is the non-stochastic DAC and the factor 25 mrem /DACus. If the radionuclide does not have non-stochastic DAC, an organ is identified 1 under the corresponding ALIlisted in 10CFR20 Appendix B.

From a review of RPM 1.4-9, the assessor noted that sources of the data

! were not cited for any of the retention factors provided in Attachments E (Whole Body), F (Diagnostic Lung), G (Diagnostic GI), and H (Excreta).

It appeared, however, that all but the last page of reference H, above, were data from NUREG/CR-4884. Without a source citation, extensive tabular data such as these for intake retention factors lack validity and 1

make later revision difficult.

Basis statement 6.6 for Requisite 2.7 states: "Per Regulatory Guide 8.9,

, Revision 1, " Interpretation of Bioassay Data", it is acceptable to assume that the intake occurred at the mid-point of the time period since the last bioassay measurement." Requisite 2.7 states "If the date ofintake cannot 4

be determined by RWP or other means, then the date shall be taken as the mid point between the current and previous routine bionssay." The third statement regarding this item is in the " NOTE box above step 3.2.2:

, "When the date of intake cannot be determined, the midpoint date of previous bioassay to current shall be used for intake assessment."

Page 26

_ - . __m.- -

. , , ~ . - . . , , y ___, ,__ ,_

l l

Regulatory guide 8.9 does use the word " acceptable," but uses this in terms of an assumption, and continues on to characterize this as but an

" initial" assumption, which should eventually be refined. The pertinent section from paragraph 4.1 of the Guide is quoted: "When the time of intake cannot be determined from monitoring data, . it can often be determined from information provided by the individual. When information is insufficient to determine the time ofintake, it is acceptable

.to assume that the intake occurred at the mid-point of the time period since the last bioassay measurement. This initial assumption should be refined by using any available information such as the individual's work schedule, facility operations data, historical monitoring data, and effective half-life of the radionuclides detected (see Example 2 of Appendix A)."

The Requisite statement comes closest to meeting the intent of the guidance, but like the other two cited statements, it does not address refinement ofinitial estimated time ofintake.

c. Policies and Pronram The Technical Support Document CY-HP-0002, Positional Paper for DAC-Hour Tracking and Bioassay Program, Rev. O, dated 5/6/93 describes the bionssay program established by CY in support of (then) new 10CFR20 requirements. The three parts of this program are the 1 routine (" minimum") monitoring program, the special monitoring program, and the confirmatory monitoring program. CY-HP-0002 describes these programs and presents the types, frequencies and trigger

. levels for bioassay. -

4 j The three-part bioassay program is implemented via RPM 1.4-1, RPM i

1.4-2, and RPM 1.4-3 and the program is summarized in CY-HP-0002.

, Routine bioassay monitoring is performed: at baseline deternunations; i annually; upon termination of job evolution or RCA work; and upon i declaration of pregnancy. Special monitoring is performed in the event of l facial contamination, unplanned uptake, or other unusual circumstances. j Confirmatory monitoring is performed for individuals: involved with airborne generating jobs; who have worn respirators; and for those receiving the potential of 200 DAC-hours / year. )

! l The first of the confirmatory programs is part of the Air Sampling Effectiveness program; the second is part of the Respiratory Effectiveness ,

program; the third is part of the program to comply with 10CFR20.1502 '

(b) (1) requirements to monitor and assess occupational intake for adults likely to receive, in one year, an intake in excess of 10 % of the applicable Annual Limit on Intake (ALI). CY-HP-0002 presents the rationale for  :

200 DAC-hours / year representing the 10% ALI trigger level. CY ,

monitors this at 4 DAC-hours / week, and tracks at 0.8 DAC-hours / day. l Page 27 4

,, ,,---,r- ,, , -, , , ,

i I

Special and confirmatory monitoring results are tracked for regulatory compliance in the Internal Assessment Database.

d. Detection and Assessment Canabilities i

CY will employ in-vim and/or in-vitro analyses as appropriate, as described in CY-HP-0002. The CY whole body counters are capable of detecting the gamma-emitting radionuclides of significance in the source l term. Contract in-vitro analyses would be performed for detection and  !

assessment of difficult-to-measure radionuclides and when necessary as i backup or comparison to in vim counting.

As described in CY-HP-002, screening munts would typically be i performed for routine monitoring. A screening in-vim count, performed i to detect one or more key radionuclides would typically be counted for a shorter acquisition time and analyzed with a limited library. An investigational in-vim bioassay, performed to identify as many 4

radionuclides as practicable, would typically be performed following a

, positive screening count. Acquisition time would be longer, and more extensive libraries would be used. A series of investigational counts analyzed with various efficiencies could also be used. Analogous

examples for in-vitro analyses are also presented in CY-HP-0002.

4 CY determined the WBC (FASTSCAN) detection sensitivities expressed i

as the [ activity-equivalent] unit of exposure, DAC-hours, for the six major source term radionuclides. The nuclide-specific sensitivities were evaluated against the respective amounts of a 4 DAC-hour exposure that would be retained in the body for varying times post-intake. The j evaluation is summarized in CY-HP-0002. Co-60 and I-131 were limiting in terms of the retained activity approaching the WBC sensitivity. By setting a 7 day post-DAC-hour assignment, all retained activities exceeded .

the respective detection sensitivities. For that case, retained activity exceeded WBC sensitivity by 25% for I-131 and by 75% for Co-60.

Based on this evaluation, CY requires (Requisite 2.2 of RPM 1.4-3) that individuals assigned 4 or more effective DAC-hours within a calendar week be whole body counted within 7 days of the DAC-hours assignment.

i General descriptions of methods used to determine the committed effective dose equivalent assigned as the result of an intake are summarized in CY-HP-002. Implementing requirements are specified in .

several of the procedures discussed earlier in this section.

CY recognizes the inherent limitations of Nal detectors, which are used in both whole body counters. Spectrum stripping techniques are in place to resolve photopeaks of similar energy, e.g., the 1.173 MeV Co-60 and Page 28 i

1.115 MeV Zn-65 photopeaks. A number of precautions for whole body counting are specified in RPM 4.3-5, including several which address  :

i potential for. cross-contamination and build up of contamination.

2 Examples are: removing as much external contamination as possible prior to counting; individuals being counted for possible uptakes must wear i

paper PCs; WBC equipment is sanitized weekly; WBC facility is surveyed at least quarterly and decontaminated as necessary,

e. Records and Reports

Requirements for entering, retrieving or modifying unofficial and official

) exposure (including internal) into the computerized exposure record database are in RPM l.4-8, Use of the PREM Dosimetry Data

. Management Subsystem, Rev. 2, dated 12/6/96. Methods to calculate

) DAC-hour equivalents and to calculate committed eff'ective dose equivalents from DAC-hour equivalents are specified in RPM 1.4-9, InternalDose Assessment, Rev. 4, dated 11/2/94. Methods to calculate organ-specific dose equivalents are specified in RPM 1.4-10, Organ l Specific Dose Calculations, Rev. O, dated 1/1/94. Whole body counting results, which are ultimately entered into individual exposure records, are

, generated in the course of accomplishing the requirements specified in RPM 4.3-5, Whole Body Counting (WBC), Rev. 5, dated 8/16/96.

! f. Ouality Assurance / External Review j Two individuals received internal depositions of radioactive material as a result of the 11/2/96 event, and concerns were raised relative to potential alpha intakes. Independent experts were contracted to assist in bioassay evaluations and to make recommendations regarding the bioassay

program. A primary recommendation was to obtain fecal samples within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of the event. RPM 1.4-9 did [still] specifies waiting at least 4 l

!i days to obtain a fecal sample. In this case, CY obtained the fecal samples six days after the event. This precluded a definitive determination of the mode ofintake (fraction inhaled vs fraction ingested), which introduced a greater degree of uncertainty into the result. Several of the bioassay

procedures are currently being revised to incorporate the consultant's recommendations. These procedures include RPM 1.4-3, RPM 1.4-4, and 1.4-9. Among the items already changed is Requisite 2.6 for RPM 1.4-4; i

this used to specify a 4 day wait to collect fecal samples, it now specifies "as deemed necessary by the Health Physicist. The consultants have .

recommended it be changed again, to specify collection "within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />."

, The Health Physicist indicated that for these internal exposures (primarily i j Co-60, trace Cs-137, and the alpha), CEDE determinations by WBC, fecal

analysis, and air sample analysis all agreed within a factor of three. i l

4

(

Page 29 l

l

CY had these fecal samples analyzed by ThermoNutech rather than by J

their contracted analyst. This determination was made in the days after

11/2/%, and was based on a number of factors: Brookhaven National Labs contracts with ThermoNutech for this service; BNL was reported to

, be highly satisfied with this arrangement; ThennoNutech's quality was determined to be highly satisfactory.

In January 1997, NRC tested CY whole body counting using the " Ralph" phantom. Total activity of about 25 nCi was distributed among the lungs

and the GI tract. WBC intercomparison with NRC occur about every two years. According to CY, the difference between CY reported results and the actual phantom activities differed by an insignificant amount (on the

order of 25.0 vs.25.1).

The amount of quality assurance checks and reviews incorporated into

, bioassay procedures is extensive. The blind spike sample program of RPM 1.1-8 has been discussed. RPM 1.4-6 is a comprehensive set of steps to be performed in reviewing WBC data. Requirements for review

of in-vitro bioassay data are specified in RPM 1.4-7. The PREM requirements, RPM 1.4-8, do not include QA reviews. RPM 4.3-4 i specifies requirements for daily background and source checking of the whole body counters, as well as trending of the quality control charts

which are generated as a result of this procedure. Monthly WBC system stability and background checks are specified in RPM 4.3-6. Quarterly WBC blind sample checks are specified in RPM 4.3-7. WBC QA

duplicate counts are specified to be performed at the 50' consecutive i

count and whenever an individual shows activity greater than the minimum detectable level. Monthly WBC stability checks on gain i j adjustment are specified in RPM 4.3-9.

3.2.1.3 Conclusions

a. CY is equipped with sufficient counting facilities, bioassay procedures, and contract support to make reasonable activity and dose assessments i

resulting from internal depositions of radionuclides. The bioassay program, including assessment calculations, calibrations, and quality assurance elements incorporated into procedures, appears capable of producing accurate and reproducible results. Bioassay detection sensitivities are adequate to assess DACs for the major source term radionuclides, and adequate energy discrimination capabilities exist.

Contract laboratory sensitivities were not examined; no issues in this area j were identified for analyses performed as a result of the 11/2/96 event.

b. RPM 1.410 instructions do not accurately describe methods for  ;

calculating organ-specific committed dose equivalents for the case of l

i Page 30

a_.c __

intake by ingestion. RPM 1.4-10 inclusion of" Remainder" as a separate column in Attachment A, with cells for apparent data entry, is potentially misleading. The source documents for the intake retention factors listed in RPM 1.4-9 are not identified in the procedures.

c. The guidance on estimating time ofintake in Regulatory Guide 8.9 has been selectively applied in RPM 1.4-9. By following the procedure as written, the opportunity to refine an initially estimated time of intake would be lost. Such refinements would result in less uncertainty being associated with the recorded assessment of committed effective dose equivalent.

3.2.1.4 Recommendations

a. Revise RPM 1.4-10 to include factors for the calculation of organ-speciSc committed dose equivalent for intake by ingestion as well as by intake by inhalation.

b. Eliminate the column labeled " Remainder" in Attachment A of RPM 1.4-10.

c. Revise RPM 1.4-9 to include the source documents for all listed intake retention fractions, and to require periodic reassessment of time ofintake in those cases where an estimate must be made initially.

3.2.2 Records and Reports / Ouality Assurance 3.2.2.1 Background The assessment team reviewed an internal audit ofinternal exposure records and discussed with management their reviews of these records. The 1996 records of significance in this area were those for the 11/2/96 event. The 1995 records discussed in fmding 3.2.2.2 a., below also were not reviewed.

The assessor reviewed a 1995 audit and the responses to that audit. This review was performed to determine both the regulatory adequacy and the archival quality of the records, and to determine the degree of management commitment to the quality of these records. The individual exposure records are permanent records; they provide a historical accounting of exposures of record. A key element of the review was to assess the degree to which these records may serve as stand-alone, defensible documents in the future.

Page 31

4 l

3.2.2.2 Findines The only HP self-assessment (HPA-96-01, dated 5/28/96) performed in 1996 per the "Intradepartmental Audit" requirements of RPM 1.1-3, Work l

Obsermtions/ Health Physics Department Audits and Technical Support Documents, Rev. 6, dated 3/20/96, examined four personnel exposure records that contained assignment of calculated internal or skin exposures in 1995.

Seven deficiencies were identified, and six recommendations for corrective action were specified. The corrective actions were tracked in the HP Records <

Department Action Request (DAR) database ')

i The self-assessment identified several deficiencies. Two forms were missing required entries. Two deficiencies involving missing support documentation

, were noted (input parameters used to perform VARSKIN calculations, <

surveys performed as follow-up to skin contamination). A discrepancy was i

noted between a manual calculation and the corresponding PREM entry. ,

, Clarification was required on a filed PREM equivalent (to NRC Form 5) form which has been revised. A perceived problem for later data retrieval was noted due to the lack of specific identifying information on data sheets i

forwarded to the NRC. Corrective actions were specified addressing each of these deficiencies, and the more global action was required to develop a

! check-off sheet, for use when dose calculations are performed, "to ensure that

all supporting documentation is included in the personnel exposure file for each incident." Eight specific items were recommended to be included.

i The assessor reviewed the responses to the corrective action requirements.

l According to the DAR tracking system, all items were closed out by the

, established due dates. One of the responses was not found in the record file. l The dosimetry technician (former records clerk) obtained a copy of the I i

response the following day (document source was located at another site).

This response addressed three of the action items. There was no indication of ,

i approval by Health Physics Management for any of these responses which l

, closed out the action items.

Blind spiked WBC samples are analyzed quarterly by the requirements of RPM 1,1-8. CY shares a contract with Millstone to have these samples

spiked and to have the contract laboratory report test results. Radiochemistry blind spiked samples, also analyzed by HP personnel, are included in this contract. RPM 1.1-8 additionally requires the quarterly analysis of interdepartmental splits of unknown spiked samples with the Chemistry Department. Results are recorded on Attachment A to the procedure.

Attachment A lists acceptance criteris and contains a " Corrective Action (if necessary)" block. The completed form is forwarded to the HP Manager / Designee for approval following the Reviewer's signature. These J

Page 32

completed Attachment A results have not been reviewed since the previous Senior Radiological Engineer moved to another facility last year.

The assessors reviewed the internal ano etanal dose assessments performed as a result of the 11/2/97 incident. Internal dose assessments were performed by consultants, Dr. George E. Chabot and Dr. Clayton S. French, and are presented in their report Emluation of Intakes by Two Workers at l Connecticut Yankee Atomic Pouer Company, dated Dec. 26,1996. The results of the internal dose assessment were reviewed and accepted by staff health physicists from CY. The dose assessment evaluated the dose using both fecal analysis, whole body count data, and air sample results. The analysis of both the fecal samples and the air samples were conducted by an independent laboratory. Measurements substantiated specific assumptions relative to the ratio of material ingested and inhaled. Based on those assumptions and evaluation of activity against established ALIs, final assessments were developed. Various assumptions were utilized to bound the doses, with the most limiting (highest dose) assumptions used for tl e dose of record. For both individuals involved, the internal doses were below (approximately 10% or less) the regulatory limits using the conservative assumptions.

External dose assessment, including lens of the eye and extremity doses, were conducted by health physicists of NU. The results were reviewed and concurred with by Dr. Chabot and Dr. French. The assessment included time and motion studies and TLD tree exposures to the actual material involved in the 11/2/96 event. The results of the external dose assessment established that the limiting dose relative to regulatory limits was the whole body dose.

Again, no regulatory limits were exceeded, the doses being a small fraction ( <

10% ) of the limits.

3.2.2.3 Conclusions

a. There is a lack of attention to detail in record generation as evidenced by the number of deficiencies observed on the records which are not generated frequently (and are consequently small in number and relatively easy to maintain).

b. The lack of timeliness in completing reviews of quality assurance checks such as that performed via RPM 1.1-8 degrades the quality assurance program and unnecessarily increases risk associated with the applicable counting systems and the attendant records generated since the last quality assurance review.

c. The internal and external dose assessments of the individuals involved in the 11/2/96 event in the CY fuel transfer canal provide a technically valid basis for establishing that doses received were well below the regulatory Page 33

limits. The doses assigned to individuals were based on the most conservative assumptions that could be reasonably supported by the data _

available. The use of recognized technical experts to perform the internal  :

assessment and to review the external dose assessment was prudent. l 3.2.2.4 Recommendations  ;

i

a. Establish standaeds for the content and completeness of exposure records involving the determination of skin doses and doses due to internal radionuclides. Formalize the methods of review by line management to 2 reinforce expectations of those standards on a continuous basis.

b. Evaluate the functional responsibilities and the resource requirements needed to implement the procedural requirements. Ensure that personnel 1 with the appropriate background are assigned the review responsibility i and are aware of their responsibility to maintain standards that will result ,

1 in technically accurate records that serve as stand alone, defensible l documents.

3J Respiratory Protection Program l

]

3.3.1 Background The assessor reviewed the CY respiratory protection program to verify adherence to stations procedures and Subpart H of 10 CFR 20.

3.3.2 Findings 3.3.2.1 Program Establishment Nonheast Utilities Health Physics Standard Practice #6-1, Policy on Use of Re.spiratory Protection, Rev. O, dated 1/94, constitutes the written policy statement on respiratory protection usage required by 10CFM.1703(a)(4).

The policy discusses:

The use of processes or other engineering controls m ' stead of respirators (e.g. process, containtnent, and ventilation techniques);

l -

Routine, nonroutine, and emergency use; and j 1

Periods of respirator use and relief from respirator use.

The respiratory protection program at CY has been used in a very limited

. capacity in the last several months due to the change in the plant's status.

Since January 1,1997, (about 4 months) there have only been 2 instances 4

Page 34 i

d.

i

-. ,e- ,r

where respiratory protection has been issued for protection from airborne radioactivity.

3.3.2.2 Responsibility Responsibility for implementation of the respiratory protections program is divided between two organizational elements of the station, radwaste and health physics. Respirator inspection, Maintenance, Testing and Issuance is the responsibility of the Radioactive Waste Group; Fit testing of respirators and maintenance and testing of SCBAs; and specification for use for respirators and evaluation of program effectiveness is the responsibility of health physics.

3.3.2.3 Procedures and Standards The following procedures govern respiratory protection issuance, maintenance, selection, use, return of equipment, training and qualification of personnel:

RPM 2.4-1, Qualitative Fit Test for 3M-9920 Dust Mask, Rev.

ORIG, dated 3/22/96 RPM 2.4-2, Respirator Fit Testing, Rev. 8, dated 1/1/%

RPM 2.4-3, Respirator Selection, Rev. 5, dated 10/19/94 RPM 2.4-4, Use ofRespiratory Protection, Rev. 7, dated 2/16/96 J

RPM 2.4-5, Respiraior Cleaning, Rev. 9, dated 2/20/95 RPM 2.4-6, RespiratorInspection, Rev. 6, dated 9/13/96 RPM 2.4-7, RespiratorMaintenance, Rev.3 , dated 7/15/94 RPM 2.4-8, Respirator Facepiece Testing, Rev. 5, dated 4/14/94 RPM 2.4-9, Control ofRespirators, Rev.15, dated 12/26/95 RPM 2.4-11, Charging Breathing Air Cylimiers, Rev.1, dated 10/18/93 RPM 2.4-13, Respirator Cleaning System Water Processing System Maintenance, Rev.1, dated 2/20/95 Page 35

.- . _ =- - . - - - . . . .- . .- -- .-- -

1 l

\

l l

i 3.3.2.4 Training and Oualifications Generally, no training is provided at CY for respiratory protection users. l Rather, individuals who have never worn respiratory protection are trained at Millstone Point. During periods when the contractor staff and the need for training increase, contractors are brought onsite to perform training and fit ,

i testing. l The individuals performing fit testing were trained on use of the PortaCount  ;

i system by a vendor representative. This initial training was approximately 5 l years ago. j

, l

Rep.dr of respirators is accomplished by an individual (Radioactive Waste )

Handie) gealified through training by the respirator vendor and through on  !

the job experience. Discussion with the responsible individuals indicated that I the last training was about 5 years ago, and that some refresher training would be helpful to maintain proficiency. (See Section 2.0 for conclusions and i recommendations related to training.)

3.3.2.5, Respiratory Equipment Fitting 1

i i

There are provisions to insure that individuals are medically qualified to wear j respiratory protection. The physical includes a respiratory profile.

Contractors and others not covered by the Company's physicals, are subjected

. to a pulmonary function test and blood pressure screening by a registered nurse.

Routine fit-testing is conducted at the Millstone Point facility. Occasionally a fit test is performed onsite using the PortaCount portable fit test unit. The fit test involves simulated work conditions, to include running in place, head

. movements, and deep breathing.

Prior to undergoing a fit test, the candidate to be tested must have a medical form indicating an acceptable medical respiratory profile. Procedures

.; addressing fit testing are:

RPM 2.4 1, Qualitative Fit Testfor 3M-9920 Dust Mask, Rev. ORIG, dated 3/22/%

l' RPM 2.4-2, Re.spirator Fit Testing, Rev. 8, dated 1/1/96 The assessor observed operation of the PortaCount test equipment by one of the usual operators, and witnessed the fit test of one individual. No discrepancies were noted.

}

Page 36

,,~ ,

Once tested and fit, there is a system in place to verify that a wearer is trained,

, experieued and qualified on the equipment he is to use. A " Qualified Individual Report" is maintained and used at the respirator issue point to identify qualified wearer's. The assessor noted that a current Guahfed huitviduals Report, dated April 4,1997 was available at the respirator issue point.

3.3.2.6 Selection and Use Per RPM 2.4-3, Respirator Selection, Rev. 5, dated 10/19/94, ' 2.3, only l

equipment tested and certified by NIOSH/MSHA is used. The filter equipment is certified for protection against radionuclides, radon daughters.

Paragraph 2.7 describes provisions against the use of sorbent cartridges or canisters for protection from radioactive gases or vapors.

Procedure RPM 2.4-4, Use ofRespiratory Protection, Rev. 7, dated 2/16/96 prohibits facial hair and the wearing of regular frarre glasses Contact lenses are permitted and provisions exist to provide lens inserts to employees requiring corrective lenses.

Discussions with responsible individuals indicated that the ALARA coordinator, in conjunction with the HP Operations Supervisor, evaluate airborne radioactivity hazards for specific jobs and recommend engineering controls, and specify appropriate respiratory protection when determined to be necessary. Guidelines and objectives for these activities are governed, in a general manner, by respiratory protection procedures. The specific interface with the RWP process and work control practices, however are not clearly specified. Likewise, air sampling and bioassay procedures are generically referenced in the set of procedures governing the respiratory protection program, but not specifically identified by number or title.

' l Containment systems are used. Construction is by maintenance with HEPA j ventilation provided by the radwaste group. Specific details are worked out i during pre-job planning meetings.

4

, 3.3.2.7 Maintenance Pronram ,

A program for periodic testing and inspection of respirators is implemented and governed by the following procedures:

RPM 2.4-6, Respirator Inspection, Rev. 6, dated 9/13/96 RPM 2.4-7, Re.spirator Maintenance, Rev.3 , dated 7/15/94 1

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An inventory system was in effect to account for all respirators. Each respirator was individually and uniquely identified with a numbered and color-coded tag (red for use in the RCA and green for use outside the RCA) affixed to the mask. Respirators were stored in locked cabinets with individual compartments marked with each respirator's corresponding inventory control number. Issuance was tracked by entering the respirator numberinto the issuance log.

The reviewer noted that Green tagged masks were maintained in the RCA storage area.

1 Prior to cleaning and disinfecting, procedure RPM 2.4-5, Respirator Cleaning, Rev. 9, dated 2/20/95, ' 3.2 requires that respirators be surveyed.

Paragraph 2.0 established the following loose contamination limits on respirators:

p <1000 dpm/100 cm2 pf7

<20 dpm/100 cm2 ct Self contained breathing equipment is tested and repaired by the Shipman Fire Company. Monthly inspections are conducted to ascertain changes in and  ;

, inventory of equipment (bottles, regulators, masks, etc.). Records of the ,

monthly inspections are maintained.

l 4

Specially designed breathing air compressors are used onsite for some air bottle filling operations. Per procedure RPM 2.4-11, compressor air is to be sent to chemistry for analysis each time the compressor is used. Chemistry is to analyze the sample for CO (#10 ppm), CO2 (#1000 ppm), O2 level (19.5 -

23.5%) and odor (None) to verify that the air quality is at least Grade D or better. The assessor reviewed records of Grade D analyses of breathing air l l performed for 1996 and 1997, to date. The assessor also reviewed records of i

. air compressor operations and compared the two records to verify adherence i to the maintenance of air quality standard. The assessor noted that, for each ,

t of 4 compressor runs in 1997, there was a corresponding Grade D air sample I analysis. For calendar year 1996, however, there were 13 compressor runs

, and no corresponding record of air quality analyses in any of the 77 analyses performed by the Chemistry Department. Discussion indicated that the compressor is also used to fill non-breathing air bottles which power air operated valves. In such cases, an air analysis is not required. The assessor noted that there was no way to verify the type of bottles being filled nor the

! specific bottle sampled by Chemistry.

I Discussions with Chemistry Department personnel indicated that the analysis procedure (CHM 7.5-10,Rev.12) had recently changed. Perhaps the reason there were no records in the log was because previously a two-part data l Page 38 4

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__ --_ ,__ ___ _ _ _ _ - w - ,

report form had been used. One copy of the analysis results was returned directly to the individual who delivered the sample to Chemistry for analysis.

The second copy was retained.by chemistry as the record copy. Since revision of the procedure, chemistry discontinued use of the multi-part form and the record copies of the previous year's tests would have been sent to nuclear records.

3.3.2.8 Ev 8-=h of Pronram Effectiveness The program for evaluating respiratory protection program effectiveness centers on a procedure requirement to conduct non-routine whole body counts ofindividuals who wear respiratory protection. Procedure RPM 1.4-3, Non-routine Whole Body Counting (WBC) Requirements, Rev. 4, dated 2/28/97, establishes the system of non-routine whole body counts as a means to evaluate the effectiveness of the respiratory protection and air sampling programs This procedure, however, only specifies how to select the individuals to be counted. The frequency of the evaluation, evaluation method, action levels based on results, the disposition of the results, and the responsibility for performing the determinations of effectiveness are not addressed. Discussion with the Health Physicist involved with the interpretation of the data indicated that accomplishment of these evaluations is dependent upon their initiative to .

perform the task, the nature, scope and method of which, are not documented.

3.3.3 Conclusions

a. The respiratory protection program is adequate to support operations.

b. The program for evaluating effectiveness of the respiratory protection program is 4

not defined to the extent that consistent implementation is asssured.

! 3.3.4 Recommendations

a. Improve recordkeeping of Grade D sir sample analysis by uniquely identifying the source of the air tested.

b. Document the method by which the effectiveness of the respiratory protection program is to be evaluated. I i

1 Page 39 4

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! 4.0 SURVEYS-

! 4.1 Routine Surveys 4.1.1 Backaround The Connecticut Yankee radiological survey program consists of radiation, contamination, and airborne radioactivity measurements within the radiologically controlled area, within the restricted area, and at the restricted area boundary. The l CY program procedural requirements are defined in Radiation Protection Manual Chapter 2. Surveys are performed as in rapport of the RWP program and as routine surveillance to establish compliance with regulatory requirements. The program procedures, their field implementation, and survey documentation were reviewed )

against requirements of 10CFR20, INPO guidance (INPO 91-014), and practices l observed at other nuclear facilities. Interviews were conducted with staff members, including technicians and supervisors to assess their understanding of the survey requirements and program expectations. Key procedures reviewed included:

RPM 2.2-2, Gamma Radiation Surveys, Rev. 3, dated 1/1/94 RPM 2.2-3, Beta Radiation Surveys, Rev. 4, dated 1/1/94 i

RPM 2.2-4, Surface Contamination Surveys, Rev. 6, dated 6/16/94 RPM 2.2 5, Airborne RadioactivitySurveys, Rev.10, dsted 3/3/97 i

RPM 2.2-15, Hot Particle Surveys, Rev. 5, dated 12/8/95 4.1.2 Findines l

Routine surveys are performed on a frequency identified on a Survey Matrix established by the Radiation Protection Supervisor (Ops.). The Survey Matrix is not governed by a procedure or program document. RPM 2.3-2, Health Physics Technician Duiles, Rev.15, dated 12/11/96 Attachment A, Daily /Shiftly Routine checklist, also identifies routine responsibilities for the technician staff. No inconsistencies in survey requirements exist between these two documents for daily requirements. The Survey Matrix covers all weekly, monthly, etc. requirements.

RPM 2.2-2, Gamma Radiation Surveys, Rev. 3, dated 1/1/94, RPM 2.2-3, Beta Radiation Surveys, Rev. 4, dated 1/1/94, and RPM 2.2-4, Surface Contamination Surveys, Rev. 6, dated 6/16/94 provide specific instruction on the methods used to perform the surveys, but do not establish requirements for when to perform the Page 40 l

I 1

1

1 L surveys. RPM 2.2-5, Airbome Radioactivlsy Surwys, Rev.10, dated 3/3/97, Sections

' {

2.2 and.2.3 provide detailed guidance on when air samples are required and when j

) they should be considered.

l A review'and approval of surveys and air sample analysis by the Radiation Protection i

Supervisor (Ops.)/ Designee is required by the survey procedures. The time frame in j

, which the review must be completed is not specified by procedure. A review of surveys performed through the end of March 1997 indicated that all surveys were ,

j signed as " REVIEWED BY" by the Radiation Protection Supervisor. The review i j date ranged from 1 to 7 days following the survey, however most of the surveys

indicated about I to 2 days from survey to review.

Surveys are documented on a standard form which contains information related to the i

area, purpose, date, technician performing the survey,-instrumentation, maximum i

, radiation and contamination levels, and a layout drawing of the area with survey

information. Procedural guidance establishing the standards for differentiating beta, gamma, neutron, and contact measurements on survey forms could not be established.

j Documentation reviewed did not indicate any beta or neutron radiation surveys.

Contact readings were typically indicated with an asterisk. Some survey forir.s

, indicate that the asterisk represents a contact reading. Other survey forms hm no ,

indication as to the meaning of the asterisk. Discussions with several tecamcians -

indicated that the asterisk is used to indicate a contact reading.  :

1

' Daily surveys of the Primary Auxiliary Building performed on February 3,4, and 5, 1997, and on February 20 and 21,1997, rhowed inconsistencies in areas surveyed and in the establishment of maximum radiation levels. Each survey was reviewed by the Radiation Protection Supervisor. No indication was found as to the acceptability of not sm veying areas that had been previously surveyed under this specific daily survey )

requirement.

l 4

The Survey Matrix form used to coordinate survey requirements is not always completed indicating that some surveys are not done as scheduled, or the form is not completed properly. As an example, the Survey Matrix form for the week ending i

Fcbruary 1,1997, had nine daily AMS checks without initials indicating that they had

been completed. The form is signed by the Radiation Protection Supervisor. No

! documented disposition of these required AMS checks could be identified.

! Additionally, the Survey Matrix for 1997 identified several areas to be surveyed that did not indicate what surveys were to be performed and when they were to be performed. Specifically, CLN-6, CLN-26, CLN-30, PAB-15, Sa, 5, and PAB-9 do

not contain any information or disposition.

RPM 2.2-15, Not Particle Surwyr, Rev, 5, dated 12/8/95 provides details on the i l

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methods to perform a het panicle (Discrete Radioactive Panicle) survey. The  !

i predure does not provide information regarding when or under what conditions the l

s;rveys must be performed. Neither the Survey Matrix nor Attachment A to RPM j 2.3-2 identifies requirements to perform hot particle surveys. A large number (>70%)

of the surveys reviewed contained the statement "No Hot Particles Detected." None  ;

of those surveys indicated where those surveys were performed.

4.1.3 Conclusions 1

l

a. Procedures governing the methods employed in conducting surveys are technically adequate. The procedures do not provide direction regarding when or under what circumstances the surveys must be performed. Routine surveillance

~

surveys are directed by the Radiation Protection Supervisor without a documented basis for the selected frequency and types of surveys to be performed. Periodic

review to determine ade.quacy of the routine surveillance program relative to

] changing conditions or trends is not formalized.

1 i

~ b. Performance standards for conducting surveys and survey documentation are not estelished. There is not a critical review process of surveys to ensure that high wndards are achieved. The lack of a critical review process against well-defined expectations does not allow the opportunity for feedback to the technicians. '

c. Survey documentation is inconsistent between technicians and from individual

technicians over several days. Inconsistencies in documentation result in records that require some degree ofinterpretation.

4.1.4 Recommendations

a. Formalize the bases for performing routine surveillance and requirements for  ;

periodic review ofimplementation of that process. Procedures should establish l the bases and the individual responsible for translating those bases into specific areas, frequencies, and types of surveys. The implementation document (similar 4

to the Survey Matrix) can be maintained under the direction of the procedure but ,

not as a part of the procedure. '

I

b. Develop standards for the performance and documentation of surveys.

Expectations for the performance and documentation of Beta radiation levels, i contact dose rates, hot particle surveys, etc. should be included in the procedures.

Communicate those expectations to the technician work force.

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c. Incorporate specific expectations regarding the scope and timeframe of survey i review by the Radiation Protection Supervisor (Ops.). Institute methods of

, Page 42

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l identifying when standards are not achieved and providing feedback to the technician whom had performed the survey.

d. Incorporate the survey form into a procedure to optimize consistency of documentation. Revise the survey form to include air sample results or a cross-reference to specific air sample analysis data sheets.

4.2 Surveys Performed in Sunnort of Radiation Work Permits (RWPs) '

4.2.1 Backtround Radiological surveys performed in support of various active and inactive RWPs (General and Specific) were reviewed for adequacy, quality of documentation, and e overall presentation of -diological information to radiation workers. Detailed interviews were conducted with staff members, including technicians and supervisors,  !

to assess understanding of survey requirements and program expectations. Key ,

procedures include, but are not limited to: -

RPM 2.1-2, Radiological Risk Assessment and Work Planningfor Initiation and ControlofRFP's, Rev.12, dated 2/28/97; RPM 2.2-2, Gamma Radiation Surwys, Rev. 6, dated 1/1/94; I

RPM 2.2-3, Beta Radiation Surwys, Rev. 4, dased 1/1/94; RPM 2.2-4, Surface Contamination Surwys, Rev. 6, dated 6/16/94; RPM 2.2-5, Airborne Radioactivity Surwys, Rev.10, dated 3/3/97; and RPM 2.5-4, Health Physics Job Cowrage Requirements, Rev.12, dated 2/28/97; 4.2.2 Findinas

a. The radiation and contamination survey information presented in the " survey measurement" section of the RWP is presented as text only, and is usually listed as a range of the minimum and maximum radiation / contamination levels in the l

area referenced. l

b. Surveys that provide the basis for the survey information presented in the RWP are not kept with the RWP. They are, however, available for the Health PhyJics technicians and Radworkers to review in pre-job briefings. Some surveys I reviewed reported ranges of contamination levels only, and others did not tie Page 43

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t -

smear results to specific locations on a survey map.

c. Surveys that are performed in support of a RWP are not referenced on the RWP.  !

Although the survey sheets generated as a result of these surveys indicate the RWP number, there is no cross-reference to the survey contained on the RWP.

d. Air sample parameters (e.g., RWP number, time taken, results, etc.) are not documented on the survey sheets with radiation and contamination survey information. Instead, procedure RPM 2.2-7 requires entry of this information on ,

the Air Sample Count Sheet and the Sample Count Log. However, RWP  !

references are not always provided, or are not accurate. For example, the assessor noted the Air Sample Count Sheet completed for an air sample (control no.

031408) taken in support ofRWP 0029, Rev. 00, Job Step 2 - RHR Pit - Security Search, contained no reference to the RWP in the designated section of the form.

Likewise, the count sheet for an air sample taken in the PAB pipi. teach (control no. 031407) contains no reference to a RWP. The Air Sample Count Log was also reviewed regarding these air samples. Although RWP information .was included, the RHR pit air sample was referenced to the incorrect Job Step (i.e.,

- Job Step 1 not 2). The sample for the PAB pipe trench was referenced to RWP 4, 4 Job Step 1, although it was used to support RWP 29, Job Step 3.

e. Surveys do not always include the location and type of radiological boundaries in the area.

l> f. The resuivey frequency is not always clearly identified on the RWP.

4  ;

g. General radiation survey information posted at the entrance to the PAB is not easily noticed and could be missed by workers. Although minor discrepancies were noted between the posted information and the most recent routine survey, the posted data generally was accurate. This posted information is not dated.

h. The surveys reviewed in this assessment received documented, timely review by the Health Physics Supervisor (Ops.). Most surveys were reviewed within one day.

i. Contamination surveys for areas frequently accessed (e.g., chemistry sample sinks, I&C and electrical maintenance work areas in the PAB) were not available at the work area.

4 Page 44

4.2.3 Conclusions

a. The radiation and contamination survey information on the RWP does not provide a clear, detailed presentation of the radiological conditions of the work area.

i

b. T1.e survey information used to generate RWPs is not readily identifiable. The system used to cross reference surveys (including air samples) and RWPs is not  ;

always followed, and it can be cumbersome to collect all survey data generated in support of an RWP.

2

c. RWP surveys do not always include maps or sketches. This made it difficult to  !

. obtain a detailed understanding of the radiological conditions of some of the work areas reviewed (particularly relative to contamination levels).

d. Although the survey information evaluated had received timely review by the Health Physics Supervisor (Ops.), there is no procedural guidance regarding the expectation in this area, e.g., maximum timeframe for this review, evaluation criteria, etc.

e. Informational posting of survey information is not dated, and workers are therefore not aware of the timeliness of the information.  :

i 4.2.4 Recommendations

a. Include, as an attachment, RWP survey documentation with the RWP as an integral part of the RWP package. These surveys should be clear, detailed, and easy to understand by the workers. Maps or sketches should normally be 4

included, and survey information presented specifically tied to the work area.

i

b. Eliminate the survey information portion of the RWP. Listing wide ranges of radiation and contamination levels on an RWP is oflimited value, and should be

avoided.

d 4

c. The resurvey frequency should be specifically stated on the RWP. Currently only  !

task specific surveys are typically included on the RWP as a Special Instruction.

, Although, resurveys are periodically performed, there is no corresponding minimum requirement on the RWP.

d. Revise the survey form to include air sample results. This would allow all pertinent survey results (i.e., radiation, contamination and airborne radioactivity measurements) to be included on the same document. Retrieval of survey information would also be facilitated.

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e. Incorporate specific npectations regarding the scope and timeframe of the Health Physics Supervi:u. (Ops.) review of surveys into the appropriate procedure.

These criteria should specify that the review be completed as part of the development and ongoing assessment of the RWP.

f. The posting of survey information at the entrance to the RCA is a good practice.

This information should be made more readily evident to workers entering the RCA, and should contain information indicating its timeliness (e.g., valid until date).

g. Post survey information (i.e., contamination levels) near frequently accessed contaminated work areas in the RCA. Possible locations would include chemistry sample stations, I&C and electrical maintenance work areas, and other comparable locations.

Page 46

l 5.0 POSTING AND AREA CONTROLS l 5,1 Backuround The assessors reviewed physical barriers, area classification and identification, requirements for entry, communication to workers, and labeling. The assessment consisted ofinterviews with plant personnel, observation of activities in progress, walk throughs of the RCA, and review of applicable procedures including, but not limited to:

NUC RPM 5.1.2, Posting ofRadiological Control Areas; RPM 3.2-1, Radioactive MaterialStorage, Marking andLabeling Requirements; and RPM 1.1-6, Control ofRadioactive Contamination Any posting problems identified during the assessment which required immediate attention were brought to the attention of the Health Physics Manager (Acting) when they were discovered.

5.2 Findines Although no serious posting violations were noted during plant tours, varieties of issues were discovered. For example, two areas were posted as Radiation Areas; however, all accessible routes into the area were not conspicuously posted. In the first case, the assessor found a single Radiation Area sign mounted on a stanchion near a pump in the PAB. The posting was suspicious since it was located nearly adjacent to an ALARA informational sign indicating the dose rate was less than 2 mR/hr. The posting did not adequately identify the affected area, and the HP Manager (Acting) was notified. After investigation and follow-up, it was determined that the posting had apparently been moved, and was originally intended to identify an area on the opposite side of the hall, around a pipe to a waste gas tank. The area around the pipe was then surveyed, and as expected based on the status of the system, no posting was necessary.

A second problem was noted in the PAB near the Reactor Coolant Radiation Monitor and the Purification Pump. In this case, a single stanchion was found with Radiation Area posting, since the posting was confusing, the HP Manager (Acting) was informed. It was learned that the posting was intended to address both areas. The single stanchion, however, did not provide adequate identification of the two areas. Additionally, an access route to the Purification Pump area existed in which one would not encounter the posting. Upon further investigation, it was determined that neither area met the criteria for Radiation Area and the posting was removed.

The entrance to the Containment was not posted as Radiation Area when first observed.

This posting was added when brought to the attention of HP supervision.

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l l

l General inconsistencies in the posting of certain types of areas were also noted. This is particularly applicable to the posting of Contaminated Areas. For example, some Contaminated Areas were identified by both rope as well as Radioactive Material (radmaterial) tape on the floor, and others did not include the tape on the floor. In addition, some plant equipment was observed with Contaminated Area posting and/or tape directly on the equipment, however, the affected area was difficult to determine. For example, a chemistry sarapie sink near the Valve room in the PAB contained radmaterial tape along the bottom of the lower section, and a Contaminated Area posting was positioned on the upper portion of this section. It was not clear if the entire lower section and the material / equipment inside this area were considered contaminated. Other examples included, posting of a HPCI valve and posting / rope around a valve and pipe on an oil supply system for the Charging Pumps. A Contaminated Area in the Valve Room was observed with handwritten instructions on a step-off pad, and the area boundary was inadequately identified. Finally, posting of some Locked High Radiation Areas contained an insert requiring notification ofHP prior to entry, while others did not.

Posting and labeling of catch basins were also found to be inconsistent. Some applications I included posting as Contaminated Area, along with Radioactive Material tape along the edge of the plastic or steel basin (ex. basin on LPCI), others had no posting or labeling (ex.

basin on HPCI). Additionally, there was no method of determining if the liquid contained within the tygon tube from the catch basin to the drain was contaminated. Procedure (RPM 3.2-1) requires tags informing workers to contact HP prior to removing equipment or material that crosses boundaries between clean and contaminated areas (e.g., tygon tubes from the catch basins to floor drains). These tags were not always present or were positioned too far from the drain. This problem was particularly apparent in the A HPCI l area. Many inputs to the floor drain were improperly tagged, and one line had come out of l the drain completely.

The HP Manager (Acting) discussed some of these posting concerns at the daily staff meeting on 3/26/97.

Deficiencies were noted in the labeling of some radioactive material in the plant. Examples include the use ofimproper labeling on the temporary pipe trench floor plug and incomplete '

labeling on a vacuum device in the PAB. The floor plug was wrapped in yellow plastic with tape referring to internal contamination. There was no radioactive material tape used, and the dose rate was not specified as required by RPM 3.2-1. Bags were placed over the ends of the hose for the vacuum device, however, the labels used either did not include the dose rate, or it was difficult to read. Also, the containment equipment vent header sample rig had radioactive material tape over an opening in the back of the rig, but no tape was applied to the access point in the front.

Page 48

Observations also included numerous empty containers labeled as radioactive material. This is the result of procedural requirement to label all containers used to transport tools or i

equipment with fixed contamination to and from job locations regardless of whether or not they are actually in use. Transport containers such as wheel barrels which were not i currently in use were observed containing material with no additional labeling (i.e., dose j rate). A bucket found in the ISI area was found to contain radioactive material and a note  :

that it was going to Millstone. The dose rate was not specified.

Labels did not identify the surveyor or date of survey. l l

The identification of tools and materials with fixed contamination less than 10,000 cepm or ,

, 2 mR/hr was inconsistent. Methods observed included the use of radmaterial tape and paint, l l however, the HP staffindicated that not all tools were indeed marked with either of these

{

i methods. Material exceeding these criteria are required to be placed in yellow striped bags

. and labeled.

s Procedure RPM 3.2-1 requires labeling of trash and protective clothing containers to indicate "a contact dose rate less than 5 mR/hr or the actual dose rate if greater than 5 mR/hr", as opposed to recording the lower limit of detection of the survey instrument (e.g.,

1

<0.2 mR/hr for a RO 2; < 2 mR/hr for a RO-2A).

l 5.3 Conclusions

a. HP technicians performing surveys are not always verifying area posting and boundaries, ensuring the posting is clear and easy to understand, and that all accessible !

, routes to the affected area are posted. Radiological postings are one of the most visible elements of the Health Physics program and consistent, clear posting is essential.

l b. Normally, a single stantion will not be adequate to clearly identify an affected area, and i

be visible from all accessible routes. The use of a single stanchion also involves more l

risk since any inadvertent or unauthorized movement of the stanchion will likely result  !

i in an improperly posted area. '

c. Program requirements and expectations for posting Contaminated Areas, plant equipment, and catch basins are not clearly defined nor understood by HP technicians.

' 1

d. Labeling requirements are not always followed.

l i e. Procedures do not require the surveyor and date of survey to be included on labeling. i

f. Tools with fixed contamination are not clearly and consistently identified.

a

)

Page 49

g. Personnel installing catch basins and tygon tubing drains do not consistently adhere to requirements regarding the use of tags on items crossing boundaries between clean and contaminated areas.

5.4 Recomanendations

a. Emphasize to HP technicians (including contractors), management expectations regarding the posting of areas. Particular attention should be given to the preferred methodology for the posting of Contaminated Areas and equipment, and the importance of proper labeling. Also, stress the importance of questioning confusing or suspicious posting and verifying the boundaries of existing area posting (in accordance with the ALARA '

concept). This may be accomplished through retraining, or other appropriate means.

b. Reevaluate the practice of using single stantions to post areas. Ropes or ribbon should be used as needed to clearly identify area boundaries and to identify small areas.

c. Develop additional posting guidelines to supplement the requirements of NUC RPM 5.1.2.

d. Develop procedural guidance (none currently exists) regarding the proper posting and labeling of catch basins, and provide the appropriate training to HP technicians. Consider the use of yellow sleeving or radioactive material stickers to identify tygon tubes which contain contaminated liquid.

i \

e. Reinforce with plant personnel not to move or alter radiological postings, and on the i proper use of the tags required when crossing contaminated area boundaries.

l

! f. Revise RPM 3.2-1 to require that the surveyor and date of survey be included on  !

radioactive material labels. Include guidance regarding the proper labeling of tools with l fixed contamination levels below the criteria in section 2.11.

g. Develop and implement a formal method for designating and approving radioactive material storage areas in the RCA. This will ensure HP personnel are aware of such areas, and improve control of this material.

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6.0 INSTRUMENTATION The assessment team reviewed the instrumentation used in support of the radiation protection program. Included in this review were portable and fixed radiation monitoring i instrumentation which are maintained and operated by the Health Physics Department. The c review included calibration, maintenance, quality assurance, adequacy to task, observations of facilities, observations of the use ofinstruments, and associated records. The findings are based on the evidence gathered by detailed interviews, record reviews, and observations of work.

6.1 Suitability and Use 6.1.1 Backaround This review included the evaluation of available instruments with respect to adequacy for intended function. Pertinent procedures were reviewed and the operation of selected portable and fixed instruments was observed.

6.1.2 Findines The instrument inventory list maintained by the Instrument Calibration Facility, Health l

Physics Services Group contained 397 portable or " semi-fixed' (e.g., AMS) l instruments. The status of these instruments was as follows:

l In Service 290 (73 %)

Not In Service 97 (27 %)

Discussions with Calibration Facility personnel indicated that the instruments listed as "Not In Service" are not needed for current use. These instruments were characterized as being, in general, excess to current or future needs. Seventy-nine (79) instruments (including both In Service and Not in Service) are located at the Emergency Operations Facility (EOF).

The " fixed" instruments in this inventory are:

)

Portal Monitors (6 in service);

Personnel Contamination Monitors (6 in service);

Waste Sorting Table (1);

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i Waste Curie / Bag Monitor (1),  !

I Small Article Monitors (2 of the 3 SAMs in use are on the inventory),  !

Whole-body counters located at the EOF (2).

HP Count Room instruments are calibrated by the HP Operations Group. This instrument array includes two (2) Gas Flow Proportional Counters and two (2) l Germanium based gamma spectroscopy systems. One of the two Gamma l spectroscopy systems had just recently been purchased and was in the process ofinitial

{

set up.

l l

Based on discussions with HP Service Group supervisors, the plant has ordered new l

, instrumentation, including Beta-Gamma field counters (Model BC-4), and alpha ,

F survey instruments (Ludlum 177 with alpha probe), designed to enhance monitoring capabilities for current conditions. Documents related to the evaluation of potential new instruments were reviewed. New instrumentation in support of future decommissioning efforts will be evaluated for purchase after the reassessment of isotopic mix is completed. The Calibration Facility Supervisor and the Senior

. Radiological Engineer have made site visits to Yankee Rowe and Fort St. Vrain, i respectively, as part of this evaluation process.

1

The HP count room is operated by technicians assigned on a daily basis or as needed j based on individual samples taken by the technicians. Daily efficiency checks using '

, both alpha (Am-241) and beta (Cs-137) sources are performed on the gas flow proportional counters. Daily checks are recorded in accordance with procedure. The

technician verifies that the efficiency falls within the acceptance criteria then forwards i the data sheet to the Health Physicist. The Health Physicist is responsible for maintaining a control chart for each of the instruments. The assessor noted that

! although the data sheets appeared to be reviewed as they were received, data had not

been entered into the control chart computer program for several months. Daily energy ,

and efficiency checks were performed on the gamma spec system. Additional gamma

spectroscopy systems are maintained and operated by the Chemistry Department.

l The Instmment Calibration Facility supervisor stated that he is consulted whenever l new instrument procurement evaluations are performed. A recent example of this was his involvement in the " Alpha Task Group." This group made recommendations for l new instmmentation to enhance alpha airborne activity determinations based on evaluation of the November 2,1996 events.

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l 6.1.3 Conclusions

a. The inventory ofinstrumentation and suppon equipment is adequate to implement the radiation protection surveillance program to the standards required by the regulations and license specifications. Portable survey instruments and fixed (dedicated) instruments are present in sufficient numbers, types, and operational characteristics to suppon implementation of the scope of current routine radiation protection surveillance activities.

b. The Gamma Spectroscopy system operated by the Chemistry Department and the system operated by the Health Physics Departments have similar capabilities. Each ,

Depanment maintains a separate laboratory quality control program for their system. Efficiency and quality of the laboratory QC would be enhanc~i if a single ,

QC program were maintained by a single Depanment. Decommissioning activities )

will alter the scope and nature of the analytical needs. The needs themselves will l change throughout the duration of the project.

6.1.4 Recongnendations

a. Evaluate combining all radiological analytical capabilities under one Department.

The selected Department should be assigned responsibility for all lab quality control. The operation of some equipment, e.g. gross counting equipment, could be performed by any qualified technician within defined guidelines, to expedite flow of data for field radiation protection activities.

b. The selection of personnel to perform instrument selection, calibration, maintenance, repair, and related supervisory activities should consider the background, experience, and training of the individuals in relation to the type of equipment that will be used to suppon the commissioning project. Provisions should be made for formal training in this specialty if the selected individual does not possess the requisite background and experience. (See recommendation 1.4.a.)

6.2 Calibration. Maintenance. and Facilities 6.2.1 Background The review included direct observation of calibration facilities, equipment, records, and calibrations in progress.

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6.2.2 Findines 1

i Operation of the calibration facility is the responsibility of the Health Physics Services 4

Group. Ponable instrument calibrations are performed by assigned HP technicians at the dedicated Instrument Calibration Facility located inside the main Radiologically

Controlled Area. All instruments are calibrated onsite with the exception of a few 2

dedicated secondary calibration instruments such as the MDH and R-meter, which are j calibrated off-site. In the past, portable instrument calibrations were performed by the I&C Depanment. The calibration function was moved to the HP Depanment several l years ago. Semi-fixed and fixed instrument systems are calibrated in place by either the Calibration Facility HP technicians or by HP technicians assigned to the Operations Group. i

, The reviewer observed the performance of calibrations of a ponable ratemeter (RO-2) l l and a continuous air monitor (AMS-2). All test equipment used was in calibration.

The response checking and the operation of some ponable and 6xed instruments were observed and reviewed with respect to procedural requirements.

The reviewer noted that the performance steps in the Precalibration Checklist for four portable dose or count rate meters contain incorrect directions. These checklists were contained in procedures: RPM 4.1-2, Calibration of the Eberline RO-2 Series, Rev. 3, Dated 7/3/95; RPM 4.1-6, Calibration of the Dositec AR-20, Rev. 3, Dated 7/3/95; RPM 4.1-10, Calibration of the Dositec PR-2 and DOS 600, Rev. 3, Dated 7/3/95; and RPM 4.2-4, Calibration of the Eberline PS-2-2, Rev. 2, Dated 8/20/93. Step

, 3.2.3 of the Precalibration Checklist in calibration procedure, RPM 4.1-2 Calibration i of the Eberline RO-2 Series is preceded by the statement, " NOTE Steps 4,5 and 7 j do not apply to this procedure."

l The reviewer noted that:

~

1) Steps 4 and 5 of the Precalibration Checklist (Attachment B, page 8) do apply to this procedure; and

2) There is no " step 7" - the checklist ends with step 5. l

The other three procedures contain analogous discrepancies. These items were I brought to the attention of the Calibration Facility supervisor and the HP Services

Group supervisor. Temporary Procedure Changes were initiated for all four of these l procedures.

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Several of the portable instrument calibration procedures require a repeat exposure to  !

either 20% or 80% of full-scale deflection followbg the check at intermediate points and electronic adjustment. Steps 3.3.2 and 3.3.8 of RPM 4.1-2, Calibration of the Eberline RO-2 Series, Rev. 3, Dated 7/3/95, is one such example. The electronic adjustment is required only if the check falls outside a specified range. Based on direct observation, and confirmed by subsequent interviews of all Calibration Facility personnel, it is the practice to not repeat the duplicate exposure if no electronic adjustments were made. The procedures do not have provisions to skip the duplicate exposure.

The Calibration Facility Supervisor and the two HP technicians assigned to this facility are senior individuals with significant experience. A third technician position was not filled when the individual filling the position retired a few years ago. The Calibration Facility Supervisor is scheduled to retire late in 1997. The HP Services Group Supervisor has identified a replacement from within the existing Radiation Protection Department staff.

Training of Calibration Facility personnel has been accomplished primarily by OTr.

These individuals are not IAC technicians. This has been supplemented by occasional instrument-specific training (e.g., WB Counter). One technician attended a commercial vendor instrument calibration and maintenance course in 1996; the other is scheduled to attend this year.

Inoperative portable instruments are stored in the Calibration Facility and repaired if the instrument is needed. Calibration Facility personnel indicated that repair of instruments 1n Use does not significantly impact the existing resources.

" Troubleshooting" or instrument maintenance history logs are not maintained at the Calibration Facility. The supervisor indicated that the only record of this nature would be the work orders completed after any instrument repair. Completed work orders are sent to Work Control.

' AC-powered air samplers are permitted to be placed into service even if the 1.5 CFM portion of the calibration does not pass, provided the 3 CFM portion of the calibration passes. (See procedure RPM 4.5-2, Calibration ofRadeco amiF&J AC-Powered Air Samplers, Rev. 2, Dated 8/20/93) In this event, a sticker is placed on the sampler ,

stating " CALIBRATED AT 3 CFM ONLY." Several samplers routinely fail the 1.5 CFM test while passing the 3 CFM test and are placed in service with the required label.

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l Calibrations due are printed ahead of time on a monthly basis. This printout is used to i schedule work. Calibration Facility personnel indicated that they have no difficulty with return ofinstruments prior to expiration of calibration. The reviewer noted that the reason was not that the instruments were returned on time, but rather because the instrument technician knows everyone and tracks them down. The assessors reviewed i records of calibrations completed in the first two months of 1997. Completed

, calibration records for the first quarter of 1997 have not been sent to Nuclear

Documents for archiving. 1 The assessor reviewed source certification records racele to the National Institute 3

of Standards and Technology (NIST). No problems wers *

.dfied.

t The assessor noted that, although the Eberline Mini-Pulser was listed in the Requisites of procedure RPM 4.2-5, Calibration of the Eberline AMS-2, Rev. 4, Dated 11/28/95, I the specific model number and the electrostatic volt meter used in the process were ,

, not. The electrostatic voltmeter is used to determine whether the voltage is 900 V +/-

, 10 V. If not, the instrument is to be sent to the IC & E Department for repair."

l 6.2.3 Conclusions

a. Calibrations are up to date for those instruments carried on inventory as In Service. Calibrations are traceable to a recognized standard.

b. The following procedures contain conflicting instructions, improper references and

) ambiguities:

i Procedures RPM 4.1-2, Calibration of the Eberline RO-2 Series, Rev. 3, Dated 7/3/95; RPM 4.1-6, Calibration of the Dositec AR-20, Rev. 3, Dated 7/3/95; RPM 4.1-10, Calibration of the Dositec PR-2 and DOS 600, Rev. 3, Dated 7/3/95; and i

RPM 4.2-4, Calibration of the Eberline PS-2-2, Rev. 2, Dated 8/20/93.

l c. Instrument maintenance history logs are not retrievable.

. d. Relocation of the calibration facility will be necessary because of decontamination

,' and demolition activities, as well as changing personnel traffic patterns and control Page 56 4

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points. Improper scheduling of the move may seriously impact the ability to efficiently support the field program i 6.2.4 Recommendations

a. Modify existing calibration procedures to eliminate conflicting instructions, improper references and ambiguities. The procedures should be clear delineation of steps to be followed. Little interpretation is necessary for calibration procedures. .

J Establish and enforce the expectation that the procedures shall be followed I verbatim. If the procedures cannot be followed or are incorrect, they should be j modified. l 4

l b. Consider the relocation of the Calibration Facility to a space outside the j Radiologically Controlled Area. '

c. Implement a history log ofinstrument maintenance.

6.3 O=H*v Assermace 6.3.1 Background This review included an evaluation of the daily response checks of portable and installed equipment that provides assurance of acceptable instrument operation

between scheduled calibrations.

6.3.2 Findings The Portal Contamination Monitors (Model PCM-1B) are maintenance checked daily.

Checks include operability, gas flow, and gas volume remaining. The detector screens likely to accumulate dust are vacuumed weekly consistent with the guidance ofINPO 91-0l4 Guidelinesfor Radiological Protection at Nuclear Power Stations, Revision 1, October 1995. The assessor further noted, however, that the PCM-1Bs were being source-response checked weekly rather than daily as specified in INPO 91-014, page 83 and by ANSI N323-1978.

i After discussions with Health Physics supervision, they indicated intent to return to daily response checking.

Small Article Monitors are source checked daily using a 3 nCi Cs-137 button source, centered on X and Y axis and jigged to 3 inches above bottom. Checks are logged on RPM Fonn 4.7.3-1 in accordance with procedure NUC RPM 2.11.5.

4 Page 57

I' All 18 detectors of the WST are source checked at the start of each shift using a Co-60 plate positioned 2.5 inches above the table. RPM 2.3-14 governs the conduct of these checks. No data are required on the form, only Sat /Unsat entries.

The WCM is also source checked at the start of each shift. An 8.6 nCi Co-60 source is used. Data are recorded on this form. Data are forwarded to the RPS Operations Supervisor for review.

1 Sources used for response checks of portable and fixed instruments were evaluated for j adequacy of activity, geometry, and isotopic mix. No deficiencies were noted. RM-14s and E-140s are currently response checked on all scales for meter deflection only, I using a single source (Cs- 137 or Tc-99 button sources). New Tc-99 check source discs have been ordered. These discs contain a rotating wheel that allows various thickness of attenuating material to be positioned between the source and a detector.

Procedures will be revised after delivery of these sources. The revised procedures will I specify quantitative tolerances for response checks of each scale on the RM-14 and the )

E-140.

Quality control charts for 1997 operational checks for instruments in the HP Count '

Room have not been generated and reviewed as required by RPM 2.6-1, Counting Statistics for Quality Control Limit Development, Rev. 3, Dated 9/27/96. The '

procedure requisite is 2.1: " Quality Control Chans should be generated every 30 days when manual chan generation is performed and every 60 days when computer generated control charts are used." The Health Physicist reviews the daily data sheets i for any abnormalities. Generation of control chans was several months behind. l Following identification of the delay in control chart updating, efforts were made to bring the data up to date.

6.3.3 Conclusions

a. Portal Contamination Monitors (Model PCM-1B) were being source-response checked weekly vice daily as recommended by both INPO 91-014 and ANSI

N323-1978.

b. With the exception of the sources used for friskers (RM-14 and E 140) sources used for response checks ofinstruments are of appropriate activities, geometry, and isotopic mix. Sources used for friskers are being replaced.

c. Count room instrumentation is being adequately maintained. Control chan analysis as specifled in RPM 2.6.1, Counting Statisticsfor Quality Control Limit Page 58

Development, has not been maintained up-to-date. This would provide an added degree of assurance of quality and the early warning capability.

6.3.4 Recommendations

a. Reinstitute the daily source checking of PCM-1Bs as recommended by ANSI N323-1978 and by INPO 91-014.

b. Establish means for maintaining control chans on a daily basis. Technicians should input data at the time daily efficiency checks are performed, thereby removing this task from the professional staff. This effort supports the recommendation to combine counting facilities within a single Department. Maintenance of the quality assurance aspects of the laboratory by a few dedicated technicians will allow for better focus on this critical aspect analytical work.

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7.0 CONTAMINATION CONTROL 7.1 Area Contamination Control 7.1.1 Backaround Programs in place regarding the control of contamination were reviewed as part of this section. This review included, but was not limited to, discussions with the Radioactive Materials Supervisor, HP Manager, and HP Technicians, tours of the RCA, and a review of the radioactive materials monthly report. Specific areas ofinterest included the identification and control of contamination at the source, the extent of contaminated area in the plant, and initiatives to decontaminate affected areas.

Radiological Surveys, as well as Posting and Area Controls, are closely related topics ,

that are addressed in sections 4.0 and 5.0 respectively of this report.

7.1.2 Findines A number of contaminated areas were observed in the RCA, particularly in containment, which were created in support ofwork during the outage. Many of these areas remain in existence although work is no longer proceeding. Actions have been taken to contain contamination in many of these areas.

P Catch basins were in use in a number of areas. They appeared to be properly installed and operating effectively. However, the assessor was not able to locate an inventory or similar document listing the locations of such devices in the plant.

The assessors did not observe any radioactively contaminated system leaks of any significance. However, it should be noted that many systems were not in operation at the time of this assessment.

6 Discussions with responsible individuals indicated that contaminated floor space is not tracked or trended.

The bases upon which a decision is made to decontaminate a given area are not documented.

The assessor was informed that a number of activities involving significant radiological concerns are performed out-of-doors in the RCA yard. These activities involve radioactive waste processing, such as changing of filter demineralizer elements and dewatering.

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i 7.1.3 Conclusions

a. The program to track the amount of contaminated area and to report totals to station management established in RPM 1.1-6, section 3.1.3.g, is not currently being implemented. Plant personnel indicated that they expect that this program .

will be modified and controlled in the D&D Plan.

b. It may no longer be wa=ry to maintain many areas currently controlled as {

! contaminated, as such. These areas are the direct result of the abrupt work stoppage. Contamination control measures (e.g., wrapping in plastic, etc.) which t have been taken appear adequate to secure open systems or components.

c. Catch basins are not inventoried and tracked regarding the details of the application / installation, and the location of these devices in the plant. See section 5.0 for a discussion of findings regarding the radiological posting of these devices.

d. There is minimal program structure and/or formal guidance regarding the criteria (

considered when evaluating the value (i.e., potential benefit) of decontaminating i contaminated areas. ,

e. Performing radwaste processing out-of-doors in the RCA yard increases the risk of the spread ofcontamination outside the RCA boundary.

7.1.4 Recommendations l a. Although the management and elimination of contaminated areas will be addressed i

in the D&D Plan, evaluate those areas currently controlled as contaminated to determine if any of these areas are frequently accessed. Consider decontaminating such areas if the original source of contamination is no longer a concern (e.g. work c is completed or suspended).

b. Track information for catch basins to include location in the plant, system, source  !

ofleak, etc.

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c. Regularly inspect catch basins to ensure they are effective and to facilitate timely i removal following system repair,

e. Establish specific contamination control measures in the Decommissioning Plan that are applicable to the decontamination and decommissioning of the radwaste systems in the RCA yard.

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7.2 Eautoment & Material l

7.2.1 Backaround The assessor reviewed the removal of material and equipment from contaminated areas and the release of such items from the Radiologically Controlled Area (RCA). There was limited work in progress in contaminated areas during this review. Thus, the assessor concentrated on interviewing station personnel relative to methods and practices used to remove material from contaminated areas, and reviewed applicable procedures.

The unconditional release of material from the RCA is currently being restricted as a result of the recent inadvertent release of contaminated video equipment. Since that event, numerous interim and permanent program changes have been, and/or will be, implemented to improve controls over the release of material from the RCA.

Additionally, a significant initiative is underway as part of the response to the aforementioned event, including extensive surveys of plant areas outside the RCA (e.g., warehouses, etc.). Surveys are also planned at selected offsite locations which may have received material or equipment released from the Connecticut Yankee RCA.

These survey efforts were not reviewed as part of this assessment. Permanent program changes and many planned corrective actions are not yet complete, hence, could not be reviewed. Instead, the assessor reviewed the interim corrective actions that have been implemented, current applicable procedures, memoranda, and other related documentation. Interviews were conducted with members of the HP staff responsible for managing and implementing this program, and limited observations of material being released from the RCA were made. The calibration and quality control ofinstrumentation used in the release of material from the RCA is addressed in section 6.0 of this report.

7.2.2 Findines Personnel interviewed indicated that material may not be removed from a contaminated area unless surveyed by a Health Physics technician. This occurs in one of two ways. Typically, radworkers notify Health Physics when they need to remove material or equipment from a contaminated work area, and a technician is dispatched.

The technician then performs a survey for removable contamination. Items found to contain smearable contamination above station limits are bagged, labeled and normally sent to the tool decontamination facility located in the Spent Fuel Building. Tools with contamination levels below the applicable limits are normally brought to the Page 62

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Butler Building. In the event a Health Physics technician is not available at the time, J

- the radworker normally places the item (s) in a yellow striped bag, and leaves it in the )

contaminated area. HP technicians then either survey the item (s) as described previously, or survey and label the bag. In the latter case, the bag is normally transported to the Butler Building for the item (s) to be surveyed at a future time.

The HP Department has recently implemented many appropriate actions to control the release of material from the RCA. The most significant of these initiatie-c include those listed below.

1. A formal memorandum (HP-97-045) was issued on February 28,1997 by the l t

HP Manager (Acting) which instituted the following interim compensatory I

! measures:

Material may only be released from the RCA via the SAM tool monitors.

Any exceptions (e.g., items too large for the SAMs) require the approval of the Director - Work Services (currently the Unit Director).

Material may no longer be released using the WST-18 sorting table, the bag monitor, or RM-14/E-140 friskers (except as approved above).

All tools and equipment (excluding personal items) leaving the protected area shall be surveyed prior to leaving the site.

All radioactive shipments require the approval of the Director-Work Services prior to leaving the site.

2. A Temporary Procedure Change (TPC) was made to NUC RPM 2.3.3 Rev.1, Mater /aland Vehicle Releasefrom RCAs, on 2/28/97. This change requires the use of SAMs to release material from the RCA. Any exception to this procedure requires the approval of the Director-Work Services.

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3. A formal memorandum (HP-97-065) was issued by the HP Manager (Acting) on April 2,1997 effectively eliminating the conditional release program

permitted by procedure NUC RPM 2.3.3. This program allowed items meeting certain radiological criteria (see section 4.2 of the procedure) to be released from the RCA. The subject memorandum states that this program was eliminated from Connecticut Yankee on April 4,1997, and that " material which cannot be free released will no longer be allowed to leave the RCA unless under extreme circumstances." These circumstances require the Page 63

approval of HP supervision, and a qualified Health Physics technician must

= escort the material. A second memorandum (HP-97-066) indicates that all material that had been previously logged in the Conditional Release Log has either been unconditionally released or brought back into the RCA.

4. The HP Supervisor issued two additional, less formal memoranda on March

, 13, 1997. The first addressed creation of two logs (material and vehicle) to ,

track material released from the protected area, and further prescribed the desired survey process and techniques to be used. The second memorandum

provided additional clarifications regarding

Release of material from the RCA (i.e., perform a smear survey and

, use the SAM);

Daily /shiftly HP tech duties (including daily response checks of the SAMs); and Control of the bone yard and canal site gates.

Refer to section 2.0 for findings, conclusions, and recommendations related to training

in changes to procedures and operations.

The assessors also conducted several walk throughs of the Butler building used for tool storage. The assessors noted that a chain link fence and appropriate posting l

defines that portion of the building within the RCA. The radiological condition of the  ;

tools and materials present varied significantly. For example, some contained only low .

levels of fixed contamination, and others were hgged rl hbeled awaiting a detailed l survey. There were no designated areas within the building for such bags to be )

opened and surveys conducted. Although there is an RCA boundary, it is not an l

, approved exit point, and hence there is no provision for release of materials from one l side of the building to the other. No activity was obsuved in the uncontrolled area, l

' and the assessor was informed that, in the past, this had been an area used by metal l workers. There was no evidence of unauthorized removal of material from the RCA.

The assessor also determined that there is one designated satellite RCA in the recycle ,

warehouse. The HP Manager (Acting) indicated that the area had been established l following a safety evaluation, and no items were allowed in this area with smearable {

contamination. He also stated plans were to eliminate the area, but did not specify a time frame or commitment. The area was properly posted, and secured by a lock controlled by Health Physics. An inventory of the contents, however, was not i

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available. Access _to this area is permitted only with a HP technician escort, and surveys are conducted at that time.

j Although a record of material released from the protected area of the site is i

documented (see above), as of 4/18/97 there'was no documentation generated in support of release material from the RCA following monitoring with a SAM. Only ,

items not surveyed in the SAM are required to be documented per the second i memorandum issued by the HP Supervisor discussed earlier.

f Interviews conducted with department management, the contractor providing the training regarding release of material from the RCA, and HP technicians indicated l some confusion regarding the use of the SAM for monitoring greater than one item.

Issues include accounting for self-shielding and/or the shielding from adjacent or  !

overlapping items, and the action to be taken if an alarm is received when multiple items are monitored simultaneously.

Procedure NUC RPM S.1.2 Rev.1, section 4.2.11, requires the approval of the HP i

Manager to establish a temporary RCA that will exist for greater than 30 days.  !

, However, no procedural guidance was found regarding cases that did not meet this '

3 criterion (i.e., RCAs that will exist for less than 30 days).

I NUC RPM 2.3.3 Rev.1, section 1.2, states that, HP supervision will determine if items with inaccessible areas are to be radiologically released, and establishes general criteria used to make this evaluation. Interviews with HP management and

! technicians indicated that this requirement was not being implemented. Although technicians indicated an understanding of the criteria that should be applied to such items, they did not indicate that approval was required by HP supervision. It should be noted that the procedure states this requirement in the Discussion section only, not in the attachments that provide information on monitoring requirements.

i 7.2.3 Conclusions

' a. The current interim compensatory actions discussed earlier should significantly improve control over the unrestricted release of material from the RCA if implemented consistently. However, there are no records ensuring all appropriate personnel have acknowledged and understand these measures. The training initiated on this subject will assist in meeting this requirement.

) b. The existing layout of the Butler building (specifically the RCA boundary fence) creates an unnecessary liability, i

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c. Although the conditional release program is effectively eliminated as described earlier, procedures have not yet been revised to reflect this change. i

d. Certain performance parameters (e.g., monitoring of multiple items, self-shielding) regarding use of the SAM require clarification.

c. No documentation is currently produced when an item (s) is released from the RCA using a SAM.

f. HP supervision approval is not obtained prior to releasing items with inaccessible '

areas as required by NUC RPM 2.3.3.

g. Procedure guidance regarding the establishment of a temporary RCA does not adequately address all scenarios.

h. The use of memoranda to specify changes to procedures involving activities that  ;

are important to safety is an inappropriate way to disseminate such information.

7.2.4 Recommendations

a. Revise NUC RPM 2.11.5 to include additional guidance on the proper use of the SAM relative to the monitoring of multiple items at the same time and self-shielding of the material being monitored.

b. Clarify expectations and procedural requirements regarding the monitoring of items with inaccessible surfaces.

c. Update applicable procedures to reflect the current program requirements (including documer.tation of surveys performed in support of material leaving the

, RCA). Consider development of a procedure specific to CY to replace NUC RPM 2.3.3 for control of material leaving the RCA. The conditional release program should be climinsted from NUC RPM 2.3.3, of not included in any new procedures. Documentation and control measures required for any material that cannot be free-released, but must leave the RCA due to extreme circumstances, 3 must be clearly specified in the applicable procedure.

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d. Develop procedural guidance requiring the HP Manager to approve any temporary

RCA.

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e. The WST-18 should not be returned to service in any capacity regarding monitoring items for unrestricted release from the RCA other than its originally intended purpose (i.e., a step in the mordtoring of " Green is Clean" trash).  !

l l f. Change the layout of the Butler building so that the entire building is within the i

RCA, and access to/from the RCA can be controlled at the building exit points.

Establish specific designated areas with appropriate contamination control 4

measures for the opening of bags containing unsurveyed materials.

g. Eliminate the satellite RCA in the Recycle Warehouse, possibly relocating the j material to the Butler building. Consider development and maintenance of an 1 inventory to ensure complete accountability of the items present while this area exists.

h. Determine what information has been disseminated in the form of memoranda.

Verify that the nature of the information distributed in this manner was consistent with stations procedures governing changes to procedures. Where necessary,

, make appropriate changes to the applicable procedures and distribute those ,

l i changes in accordance with plant procedures.

7.3 Personnel Contamination Monitorine

, 7.3.1 Backaround This section reviewed station policies, procedures and practices in the area of

. personnel monitoring for contamination. The assessor conducted tours of the RCA 4

and interviewed plant and Health Physics Department personnel, and reviewed i

applicable procedures, including those listed below.

RPM 2.7-12, Personne/ Monitoring, Rev. 5, dated 9/16194 i

RPM 2.7-1 3, Contaminated Personnel Survey and Decontamination, Rev.10, dated 11/29/93 4

, RPM 2.7-14, Contaminated Clothing Survey andDecontamination, Rev. 6, dated 12/8/95 1

Monitoring requirements for exiting contaminated areas, the RCA, and the Protected Area were reviewed, and observations were made of plant personnel executing these requirements. As noted elsewhere in this report, work in the RCA is currently i

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4 restricted; hance, there was limited opportunity to observe work in contaminated areas.

7.3.2 Findings Automatic whole body contamination monitors (i.e. PCMs) are located at the primary exit from the RCA, and at the containment control point. All personnel exiting these areas are required to use these instruments. HP technicians are stationed at the primary RCA exit to ensure personnel are properly monitored, and to provide assistance as needed.

1 Personnel are expected to satisfactorily pass through a PCM prior to unrestricted  ;

. release from the RCA. Based on discussions with HP personnel and direct  :

observation, the standard practice upon receiving an initial alarm is to attempt

monitoring a second time using a different PCM. Health Physics personnel typically 5

observe this monitoring evolution. If an alarm is received a second time, Health 4

Physics personnel will monitor the affected area. Decontamination is performed as necessary in accordance with the applicable procedure (RPM 2.7-3 or RPM 2.7-4), if contamination levels are above 100 cepm (beta-gamma). Iflevels are below this limit, decontamination techniques are applied, and the individual again attempts to clear the 3 PCM. Individuals are not permitted to leave the RCA until they can satisfactorily pass

through a PCM, regardless if the contamination levels are in excess of 100 ccpm.

l Although these are good practices, they are not required by RPM 2.7-2. Section 3.1 l of this procedure requires an individual to notify Health Physics, and perform a whole i body frisk (with the guidance of a HP technician) upon receipt of an alarm from the PCM. Individuals are decontaminated in accordance with the applicable procedure, i and the incident documented if contamination levels exceed the 100 cepm criteria j stated earlier. Individuals with contamination levels below this limit are considered l

clean, and free to exit the RCA. In other words, the procedure does not require ]

, individuals to successfully pass through a PCM if contamination levels are found to be  :

below 100 cepm following an alarm on a PCM, or following decontamination.

i Per RPM 2.7-2, section 2.1, personnel exiting the RCA when a PCM is not available are required to frisk hands and feet only if they have not worn protective clothing.

Personnel who have been in a contaminated area are required to perform a whole body frisk under these circumstances.

There are no personnel monitoring requirements to enter the RCA yard, e.k., from the i PAB, Spent Fuel Building, Hot Machine Shop, etc. The HP Manager (Acting) indicated that this requirement is currently under consideration.

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Several eating and drinking area " islands" (e.g., chemistry and HP instrumentation department offices) exist in the primary RCA. A hand and foot frisk is required for entry if personnel have not wom protective clothing, and a whole body frisk is required if personnel have been in a contaminated area. The HP Manager (Acting) indicated that these areas were going to be eliminated in the near future. The assessors also observed several cloth chairs in the RCA.

The assessor was informed that there has been one event involving skin contamination, and two events involving contamination of personal clothing year-to-date (as of April 30, 1997). Each of these contamination events occurred in a " clean" area, within the RCA, and was classified as a " mishap" as described in RPM 1.1-9. The Health Physicist indicated that personnel contamination events are logged in a database, and reviewed every six months to look for adverse trends. Currently, the procedure requires the circumstances leading to the contamination to be described only if they are not covered by one of the general cause classifications. This may not be adequate to obtain sufficient information to identify all contributing factors to the contamination event.

Monitoring requirement:: for exiting the satellite RCA in the recycle warehouse are not i specified in procedure. However, entry into this area requires that an HP technician be present, and individuals are instructed to frisk their hands and feet prior to exiting.

7.3.3 Conclusions I a. The number of PCMs at the primary xit from the RCA is adequate, and this area is well monitored by Health Physics personnel.

b. Plant practices and procedural requirements regarding criteria for exit from the RCA are not consistent. There is no guidance provided relative to exhing the satellite RCA.

c. Monitoring is not required prior to entry into the RCA yard.

d. There are no procedural requirements to frisk immediately upon exit from a highly contaminated or discrete particle area.

7.3.4 Recommendations l a. Revise the applicable procedures to reflect the current practices regarding exit from the RCA. Provide adequate detail to describe the desired action in case of an Page 69 I

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alarm on the PCM and for those cases when a PCM is not available. Establish specific, consistent criteria for unrestricted release from the RCA. State whether an individual must satisfactorily pass through a PCM (when available) prior to exiting the RCA.

b. A whole body frisk should be required immediately upon exit from a highly contaminated area (e.g., > 50,000 dpm/100 cm') or a discrete particle area (reference INPO 91-014).

c. Revise RPM 2.7-2 to require a manual whole body frisk prior to exiting the RCA at all times if a PCM is not available (i.e., regardless of whether or not personnel have been in a contaminated area). INPO 91-014 recommends an automated whole body frisk (i.e., use of a PCM or equivalent) when exiting the RCA.

d. Eliminate eating and drinking areas in the RCA as soon as possible.

l-I e. Require monitoring of hands and feet prior to exiting to the RCA yard. This would be best accomplished with automated hand and foot monitors.

f. Develop monitoring requirements for exiting the satellite RCA and incorporate the requirements into procedure (s).

g. Eliminate all cloth chairs from the RCA as they have an affinity to collect and

" hold" discrete particles. The plant staff has previously removed many of these chairs from the RCA, however, some remain.

I h. Review skin and clothing contamination events monthly to determine generic l causes and adverse trends as described in INPO 91-014. Ensure investigations of contamination events contain sufficient detail to determine the root cause of the event. Modify Attachment A, Radiological Tracking and Trending Information, l to RPM 1.1-9 to require a detailed listing of the specific circumstances leading to the contamination event, in addition to the overall cause of contamination listed on the form.

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8.0 WORK CONTROL 3.1 Planning and Schedulian 8.1.1 Background The assessors evaluated the methods employed by the station in the development of work plans and the scheduling of work involving radioactive material. The assessors also attended planning meetings and pre-job briefings. The Automated Work Order System (AWO) and its interface with the Radiation Work Permit (RWP) procedures were evaluated.

8.1.2 Findinas Scheduling ofstation work activities is coordinated through a T-6 scheduling process.

The T-6 process presents detailed schedules of work being performed during the present week (T-0).and work expected to be performed out through the next six weeks The level of detail decreases with each successive future week. The T-1 schedule detail is thorough and provides the input to the Radiation Protection department to create Radiation Work Permits.

All activities that will occur within the Radiologically Controlled Area (RCA),

including engineering walkdowns and other routine tasks appear to be included in the  ;

T-6 schedule.

A 1:00 p.m. meeting is held each normal work day to review the T-6 schedule. The review meeting is chaired by the scheduling group representative and is attended by  ;

representatives of the various work groups and the Radiation Protection Supervisor -  ;

(Operations). T-0, T-1, and T-2 schedules are reviewed in detail. Subsequent week schedules are reviewed in lesser details or by exception.

Details regarding RCA work within the T-0 to T-2 schedules are discussed at the 1:00  ;

p.m. meeting. The Radiation Protectian Supervisors (Ops.) exhibits a questioning i attitude regarding RCA work to develop a thorough understanding of the planned work.

Unscheduled work (e.g., emergent work) not on the T-6 schedule requires the approval of the Unit Director to be added to the work list. Twenty-four hour-advanced notice of the radiation Protection Department is required for non-emergency work added to the schedule with the approval of the Unit Director.

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Automated Work Orders provide general information regarding the component and it's maintenance requirement. The AWO's are available to the Radiation Protection Department through the station computer network. Information regarding the maintenance methods to be utilized for resolution of the AWO's is obtained by the Radiation Protection Department through verbel discussion with the work group.

Documented work packages, detailing the methods to be employed are not reviewed by the Radiation Protection Department.

All RWPs are reviewed and approved by the Radiation Protection Supervisor (Operations).

Pre-job briefings involving the workers, their supervisor, the Health Physics Technician assigned to job-coverage for the work, and the Radiation Protection Supervisor (Operations), are held for work scheduled within the RCA. The brie 5ags appear to result in an understanding of the work to be accomplished, work m.:thods, radiological conditions, and radiological controls. RWPs are reviewed by the workers. The briefings are documented and appear to result in a work team with clear l

expectations for personnel involved in the work.

t Special procedures for specific high-risk evolutions including radiography and nuclear diving operations have been developed based on station experiences in those areas. Radiological control requirements are elaborated in those procedures.

8.1.3 Conclusions

a. The control of work through the T-6 scheduling process provides the Radiation Protection Department with sufficient notice to perform surveys in support of RWP development. Provided adequate details are communicated, RWPs can be prepared sufficiently in advance of the work to allow for review by the Radiation Protection Supervisor (Operations). Emergent work challenges to the Radiation Protection Department are minimized. See section 8.2 regarding RWP generation.

b. The forcing of all RWPs through single point review and approval within the Radiation Protection Department , the thoroughness of the pre-job briefing, and the limited complexity of work being performed within the RCA provides adequate radiological control planning for the present work efforts. The Health Physics Technician assigned job-coverage responsibility is able to function in the capacity of verification that agreed upon radiological control practices occur and l

that anticipated radiological conditions are found. The job-coverage technician is appropriately functioning as a defense in depth mechanism to a work activity with preplanned radiological safety considerations.

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c. The magnitude of radiological work activities as well as the complexity of those activities anticipated during the decommissioning project will be beyond the l capabilities of the present system to support without sacrificing either the level of safety or schedule adherence. Emphasis must be placed on the development of detailed work packages that contain not only the work methods and sequences, but any work requirements or restrictions necessary to maintain radiological safety.

d. Existing procedures for high risk evolutions (e.g. RPM 2.5-1, Radiography, Rev.

6, dated 04/17/95, RPM 2.5-3, Incore Instrumentation, Rev. 6, dated 12/8/95, RPM 2.5.7, Diving Evolutions, Rev. 6, dated 11/29/95, etc.) contain sufficient specific direction regarding the controls necessary to maintain radiological safety.

Responsibilities are clearly delineated within these procedures.

8.1.4 Recommendations

a. Modify the organizational structure to include radiological controls personnel in the work planning organization. Work package development should include all activities required of the workers to achieve radiological safety, including l

exposure and contamination control, and to meet the requirements of the radioactive waste management program.

b. Integrate work package preparation with the Radiation Work Permit. The work package should contain the task description and sequencing : ecessary to achieve l radiological controls. The RWP defines radiological conditions, personnel protective equipment, stay-times, and other limitations for the worker. (Note: see recommendations under Section 8.2).

8.2 Radiation Work Permits (RWPs) 8.2.1 Background Radiation Work Permits (RWPs) were reviewed in conjunction with the Work Control program. The assessment of this area included a detailed review of the key RWP procedure (RPM 2.l-2, Radiological Risk Assessment and Work Planningfor Initiation arul Control ofRWPs) and supporting procedures (e.g., RPM 2.1-1, RWP Initiator / Job Supervisor Responsibilities, RPM 2.1-6, Radiation Worker RWP Responsibilities" and RPM 2.5-4, Health Physics Job Coverage Requirements).

Extensive interviews were conducted with the individuals responsible for developing and validating the RWP procedure, as well as the staff members and their supervisors responsible for implementing the program. The station has imposed significant l Page 73 l

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restrictions on work in the Radiologically Controlled Area (RCA) as detailed in a memorandum from G.H. Bouchard dated 3/13/97. Therefore, there was no work involving significant radiological challenge in progress during this review. Although this limited the opportunity to directly observe the application of the RWP program to such work, other evolutions in progress under various active RWPs were observed.

In addition, the reviewers performed a detailed review of the RWP used to validate the procedure (RWP no. 0024), as well as other RWPs that were not currently active during the assessment.

INPO 91-014 was used as a key reference during this review. Surveys performed in support of RWPs are addressed in Section 4.0 of this report.

l 8.2.2 Findines l

Interviews conducted with HP and plant staff revealed some confusion regarding both the basis for the change to the RWP program, and the objectives of the new program.

The assessor found that the major revision to the RWP procedure (RPM 2.1-2) was completed over approximately a three-week period and the revision was made effective on February 28, 1997. Training was not provided to Health Physics technicians or plant radworkers prior to implementing the procedure. Four technicians did attend a training session that provided an overview of procedure Requisites on March 6,1997. The revised procedure was also included on a Document Acknowledgment Sheet (Log No. 97016); however two Health Physics i

technicians had not completed this requirement at the time the assessment was conducted. This problem was identified to the HP staff, and overview training was provided to the remaining technicians. This training was completed on April 15, 1997. Also, ACR 97-0000: " Personnel training needs associated with RP procedure revisions are not being adequately evaluated and implemented" was generated regarding completion of HP technician training on all procedure revisions resulting from the Transfer Canal Event. The assessor was informed that no training had been provided to the general plant staff, and no plans to provide such training were indicated.

The HP department review of procedures that may have been impacted by the major l revision to the RWP procedure has not yet been completed, resulting in discrepancies between procedures. Examples include RPM 2.1-1, RWP Initiatordob Supervisor l Responsibilities regarding the steps necessary to initiate an RWP, and RPM 2.1-6,

Radiation Worker RWP Responsibilities regarding General and Specific RWPs.

l Temporary Procedure Change to RPM 2.1-2 step 3.1.2 (dated 3/10/97) requires the Work Planning / Work Supervisor to notify Health Physics 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> in advance of work to be performed in the RCA, and to provide information regarding the proposed l

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work. However, the procedure does not describe the method by which this information is to be provided. As a result, the Health Physics department receives such information in various forms including, e mail messages, and memoranda, as well as oral presentations at the 1300 hour0.015 days <br />0.361 hours <br />0.00215 weeks <br />4.9465e-4 months <br /> T6 Scheduling meeting. The assessor noted both through a review of the information provided, as well as interviews with the HP staff, that details regarding work scope which are necessary to determine the appropriate radiological controls for the work are often not provided until the pre-job f briefing. This has resulted in confusion and inadequate radiological planning for some work. For example, a " game plan" was developed for RWP 0024 which refers to work to be performed on the "B" PAB purge fan, and the "A" pre-filters (FL 1 A). However, there is no reference to work performed on the "B" fan in the RWP.

Some RWPs reviewed were written with multiple tasks involving different radiological conditions and controls addressed on the same Job Step. For example, RWP 0024, Job Step 1, was written to " Change Filters Inside the PAB Ventilation Plenums." The RWP was written this way even though the radiological conditions and controls for removing the filters was expected to differ from those associated with the installation of new filters.

l The assessor found it a standard practice to develop Special Instructions to address basic radworker activities or work practices which should be included in the work package. The following are examples of instructions that address activities that l should be included in the work package, or are basic Radworker work practices:

l Spray / mist alifilters lightlyprior to removal.

Outside laydown area requiredfor material! equipment transition area - see Radmaterials Techs.for washable laydown clothes l

Allfilters to be bagged inside the Ventilation Plenums prior to removal to transition area outside.

The Cover Sheet for each RWP reviewed contained identical Special Instmetions.

l The instmetions listed provide basic information that should be well known to all Radworkers.

RWP 0024 contained the Special Instruction, "No entry into High Radiation Areas",

j even though there were no such areas accessible through the RWP.

Special Instructions were reviewed which did not provide sufIicient detail and/or left room for interpretation. For example, the following special instmetions are statements that could result in changes to the work scope without the appropriate Page 75

modifications to the work package and the RWP:

No changes in work scope not coveredinpre-job briefing.

Health Physics to authorize all work on this Job Step These instructions are also subjective, in that the HP technician may allow changes in work scope if they believe the work comprising the change was addressed in the pre-job briefing. The potential for problems is particularly relevant to jobs involving shift turnover.

RWP 0024 listed the Faceshield or Respirator as Requirements. The Special Instructions that appeared on thejob steps stated:

Faceshield requiredfor removing allfilters.

Faceshield requiredfor decon work inside ventilationplenums. i l

Re.spirator requiredfor removingfilters.

'l These Special Instructions appear on the Job Steps of RWP 0024, which lists the faceshield or respirator as requirements. These instructions can be confusing to the Radworker. For example, they can be interpreted to permit access to the area without the faceshield or respirator for inspections or HP surveys while work is in progress.

Additionally, since the Job Step for " changing the filters" includes installation of the new filters, it is not clear if the prescribed item is required for this evolution.

l Another RWP 0008 lists coveralls, rubber gloves, rubber shoe covers, cotton liners,

! and booties as requirements. The special instructions for this RWP stated:

Scrubs may be used in low to moderately contaminated areas with prior HP approval.

Labcoats may be used in low to moderately contaminated areas with prior HP qqproval.

It was not clear to the assessor how the requirements of the RWP are affected when scrubs or labcoats are worn, and the RWP is no longer a clear record of what '

protective measures were actually used (i.e., there is no documentation of what was l worn).

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1 Based on interviews with Health Physics technicians the assessor found that they Page 76 l

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were not always sure which RWP or Job Step they are expected to sign in on when the Job Step does not require constant HP coverage. They stated they rely on specific direction from Supervision. In addition, as indicated on RWP sign-in sheets and in interviews, HP technicians do not always sign out of the Job Step for a Specific RWP when they are no longer performing work in the RWP area.

The Health Physics Supervisor (Ops.) indicated that pre-job dose estimates are not always performed.

General RWP No. 0008, Job Step 6: Scaffolding - Erect / Modify / Remove, contains the requirement to notify HP prior to erecting additional levels of staging so that a survey can be performed. This requirement is because the overhead is not normally surveyed, and radiological conditions are not known (particularly contamination levels).

The current system (PREM) requires a new revision of a RWP be issued whenever survey information is updated, regardless if the radiological controls specified by the RWP are unaffected by the change in conditions.

The RWPs reviewed all had the same general appearance. HP personnel indicated that the PREM system does not offer enough features to enable them to use different fonts or other visual means (e.g., bolding, underlining, etc.) to highlight important or unique information on the RWP. The only feature available in this regard is a

" starred" box around selected text.

8.2.3 Conclusions

a. Training of Health Physics and plant personnel on the RWP program was incomplete, resulting in an apparent lack of understanding of program objectives and inconsistent implementation of the program.

l b. Inconsistencies and discrepancies exist between various Health Physics procedures regarding critical elements of the RWP program.

c. Health Physics personnel are not provided with adequately detailed information from the work groups describing the work schedule and scope. Presentation and detail of the information provided by the various work groups is inconsistent.

This is the result of the fact that there is no formal documented process ensuring Health Physics personnel consistently receive detailed work planning / work scope information with sufficient time to complete radiation protection tasks.

There is too much reliance on briefings to ensure that the work scope is I completely understood by all parties.

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d. Individual RWP Job Steps are not always restricted to work with comparable or identical radiological conditions and controls. HP personnel rely on revising the Job Step to address expected or actual changes in radiological conditions and controls.

e. The use of Special Instmetions which are general, non-task specific, irrelevant, and/or subjective has caused this section of the RWP to be less effective relative to highlighting important information specific to the Job Step. In many cases, this is a result of the RWP being used as a " catch-all" for basic radiological control activities that are the responsibility of the Radworker. These practices also make the recovery of historical information regarding the actual protective measures required by the RWP less reliable.

f. Information regarding the actual time a Health Physics technician spends on a Specific RWP Job Step is not recoverable when the technician does not sign-out of the RWP when exiting the affected area. This practice results in less accurate information available from the post job review, and can cause nonconservative assumptions regarding exposure (i.e., DAC-hours assigned) to be made in the event unexpected airborne activity is discovered.

g. RWPs are very similar in appearance which can cause complacency or a " false sense of security" to individuals reviewing RWP requirements. Radworkers may not notice changes to the RWP, or may not appreciate the importance of a note or instmetion.

h. Pre-job exposure estimates are not always performed as required by RPM 2.1-2.

i. Some work, such as scaffold erection, covered by General RWPs might be better suited for Specific RWP.

8.2.4 Recommendations

a. Review the RWP program objectives to ensure that it effectively integrates into the work planning and work control processes.

b. Review the implementing procedures to ensure that all elements of the RWP program are addressed in the appropriate procedures and consistency is obtained.

Also, consider opportunities to combine procedures.

c. Task the Training Department to develop and provide training to Health Physics and plant personnel on the RWP program. This training should be Page 78

comprehensive, and should clearly present the overall objectives of the program.

The bases for essential elements of the program should be sufficiently detailed to allow personnel to gain a clear appreciation and understanding of program expectations. Include training for contract Health Physics technicians.

d. Establish a formal process for Health Physics to receive detailed work planning information. The mechanism developed must ensure adequate detail is provided regarding all job activities and evolutions which could affect radiological conditions, and that this information is provided in a consistent and timely manner. The current requirement for 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> notice may not be adequate as the workload increases. The process should also replace the current reliance on pre-job briefings to determine or clarify job scope. Please note, use of the new RCA Work Nott/1 cation /RWP Request form is a definite improvement and should be formalized ifit will be used as part of the disposition of this issue.

e. Write RWP Job Steps sequentially and provide a clear, detailed description of the job location and work to be performed. Only evolutions with comrarable or identical radiological conditions and controls should be included in the same Job Step. RWP Job Steps should be issued when radiological conditions are known, rather than depending on revision to the Job Step when this information is available.

f. Special Instructions should be reserved for unique, task-specific information and directions for radworkers. Information that is not applicable to a RWP or an individual Job Step should not appear on the RWP. Information concerning basic Radworker responsibilities or activities should not be contained in this section, instead belong in either work procedures or another part of the work package.

l Special Instructions should not be subjective, or subject to interpretation by the l

Health Physics technician providing job coverage or the Radworker. Qualifiers should be avoided whenever possible since they prevent workers from resolving questions and acknowledging that all RWP instructions and requirements are f

understood. Special Instructions must be limited to the work authorized by the specific Job Step when used.

g. Health Physics technicians should sign-out of Specific RWPs when no longer providing job coverage in the RWP controlled area.

h. Review the PREM software package to dctermine if additional features could be incorporated to allow additional means to highlight or draw attention to imponant information, and to help visually distinguish one RWP from another.

i. Review the PREM and FASTRAC software capabilities to ensure maximum use Page 79

and benefit from these systems. Additional controls appear to be available which are not currently used. For example, the software can be set-up to allow only certain individuals to sign-in on an RWP Job Step. This feature could offer an additional level of control to restrict access only to those individuals who attended the pre-job briefing that is especially important in high-risk evolutions.

j. Always calculate pre-job exposure estimates.

k. Review work covered by General RWPs to determine if the work scope is more appropriately covered by a Specific RWP. Work which requires a HP holdpoint, is performed as a supporting function to other work covered by a Specific RWP, or where the radiological conditions are unknown should be covered by a Specific RWP. ScafTold erection is an example of such work.

8.3 ALARA Prorram 8.3.1 Background The assessment evaluated the structure and implementation of the station ALARA program. The evaluations included the tracking and trending of exposure against station, group, and individual job goals, the dissemination of exposure information, and the involvement of ALARA (Radiological Engineering) in the planning, monitoring, and review of high risk evolutions. The review included the discussions with the ALARA Coordinator, review of ALARA exposure information, evaluation of the efTectiveness of ALARA involvement in the Service Water Pipe Replacement l work, and implementation of the following procedures:

RPM 1.5-1, AIARA Policy, Rev. 4, dated 2/10/95 RPM 1.5-2, AIARA Reviews, Rev.12, dated 2/28/97 RPM 1.5-7, AIARA Erposure Goals, Rev. 6, dated 1/16/95 RPM 1.5-9, AIARA Hot Spor Evaluations, Rev. 4, dated 6/9/95 RPM 2.1-2, Radiological Risk Assessment And Work Planning For Initiation and Control ofRWPs, Rev.12, dated 2/28/97 l

l 8.3.2 Findines The station ALARA policy is described in RPM 1.5-1. The elements of a substantive ALARA program exist within this document. The structure of the document is written Page 80

l to the organization, responsibilities, and long term objectives of an operating nuclear plant.

The ALARA Coordinator is administratively assigned to the Engineering Department, but provides functional support to the Health Physics Manager.

ALARA goals have been established for 1997, based on no decommissioning activities occurring this year. The goa*" are broken down by department and have been created with input from the individual depatments. Consideration has been given to modifying 1997 goals if decontamination activities occur this year.

The station is presently at about 20% of the exposure goal after more than 30% of the year. Exposure reports, updated from the electronic dosimetry system, are present each working day at the station management meeting.

RPM 2.1-2 provides guidance for the identification of high-risk evolutions that require ALARA review. Additionally, the ALARA Coordinator reviews the T-6 schedule to develop added assurance that work evolutions that should involve an ALARA review are flagged.

The assessor evaluated the ALARA involvement in the Service Water (SW) Pipe Replacement work. The ALARA review requirement was identified by the Health Physics Technicians at the RWP development stage. RPM 1.5-2 provides a detailed checklist to evaluate dose reduction technique applicability to the specific work. The work plan emphasized the prefabrication of materials outside the radiation area and minimization of time in the area of the heat exchanger. An evaluation of the benefit of shielding the heat exclanger determined that the dose associated with installation and removal of the shielding would essentially equal the savings in dose to the workers.

The shielding was not installed.

The initial projection for the fu3 scope of SW work was 1.050 Man-Rem. The work l was complete with total exposure of less than 0.350 Man-Rem. The ALARA Coordinator attributed the success to the diligence of the Health Physics Technicians supporting the work and the cooperativeness of the workers in optimizing their distance from the heater while performing the individual tasks. The large dose gradient as distance from the heater increased resulted in substantially less effective dose rates for the work group.

Documentation of the ALARA involvement in the process included evaluations, and ALARA briefing sheets used in accordance with RPM 1.5-2.

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RPM 1.5-7 and RPM 1.5-9 describe processes used during normal station operation.

They are not presently in use, however they are still approved procedures.

8.3.3 Conclusions

a. The ALARA policy and procedures establish the stations commitment to the philosophy. The policy and procedures are written for an operating nuclear station, and are not fully applicable to the decommissioning project.

b. Some ALARA procedures are no longer applicable but remain in effect.

c. The ALARA process includes methods within the RWP program to initiate involvement of the ALARA organization in high-risk evolutions.

d. The single individual responsible for ALARA reviews of high-risk evolutions and for developing and disseminating exposure information is able to fulfill the responsibilities based on the current workload. Although the ALARA Coordinator is administratively assigned to the Engineering Department, his efforts appear to be primarily in support of the Health Physics Manager.

e. The procedures associated with the ALARA review process are thorough.  ;

Documentation required by these procedures results in traceability on decisions and the basis for those decisions. That documentation allows for continuos review and improvement based on lessons learned from each evolution.

8.3.4 Recommendations

a. Modify the ALARA policies and procedures to address the decommissioning project. Procedures that are not applicable to the present and future efforts at CY should be canceled.

b. Include ALARA Coordination functions within the Radiation Protection t Department organization changes as discussed in Section 1. The functions of the ALARA Coordinator are within the overall responsibilities of the Radiation Protection Department and the Health Physics Manager.

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9.0 RADIOACTIVE WASTE SHIPPING & HANDLING The evaluation focused on the programs established to ship radioactive material from the site in compliance with the station Technical Specifications,10CFR61, 49CFR, waste processor and burial site licenses. The evaluation included the Process Control Program, and those programs used to package and ship DAW, Resin and other radioactive materials, as well as the station waste management efforts.

9.1 Packarine of DAW 9.1.1 Background The assessor reviewed Procedure RPM 3.5-6, Guidelinesfor Preparing Dry Active Waste (DA W)for Off-site Processing, Rev. 2, dated 12/8/95 as a basis for this portion of the assessment. The assessor also reviewed representative shipping packages. The purpose was to determine compliance with the Federal shipping regulations and licenses of the American Ecology Recycling Center and Scientific Ecology Group (SEG), the two DAW processors most commonly used by the Haddam Neck Plant.

9.1.2 Findines Procedure RPM 3.5-6 provides requirements to check each bag for inappropriate material (i.e., aerosol cans, containers that could contain liquids and/or hazardous solvents, reusable protective clothing, respirators, reusable tools / equipment and liquids). The procedure further specifies that appropriate personnel be notified in the event any DAW is found to not meet the procedural requirements. DAW bags are l loaded on the c-van based on the bag dose rate. The bags are divided into three groupings based on dose rate and loaded according to the groupings. This allows for

, additional packaging efliciency and internal shielding.

i Procedure RPM 3.5-6 does not have provisions to document and record the checks required by the procedure or the location in which the trash was generated.

9.1.3 Conclusions

a. DAW packaging procedure RPM 3.5-6 provides adequate guidance to meet the requirements in the DAW processor's license. However, the lack of documentation ofinspection activities does not facilitate identification of causes and corrective action in the event that problems are identified.

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9.1.4 Recommendations

a. Implement a loading / trash log. The log should contain the dose rate, the initials of the individual who inspected the bag for inappropriate material, and the location the trash was generated.

9.2 Packaring of Resin 9.2.1 Backtround

• The following documents were reviewed and used as a portion of the basis for the evaluation of this program element:

RPM 3.4-4, Dewatering of High Integrity Containers in the Spent Resin Facility, Rev.14 dated 11/22/96; Process ControlProgram QuahficationManual; Rev.1, dated 7/20/94; Nuclear Group Procedure NGP 6.07, Radwaste Quality Assurance Program, Rev.

7, dated 11/5196; RPM 3.4-1, Receipt, Inspection, Set-up andHandling ofHigh Integrity Containers (HIC), Rev. 6, dated 9/13/96; RPM 3.4.2, Set-up of High Integrity Containersfor Resin Survey In The Spent Resin Facility, Rev. 4, dated 5/14/93; and ACR-97-0076, Adwrse Condition Reportinitiation Form, dated 2/10/97.

i i ACR-97-0076 identified four conditions not being implemented in a manner that would ensure compliance with 10CFR61. These conditions were:

Failure to implement the QA Program (repeat finding);

Failure to revise the QA Program to reflect a decommissioning status Failure to collect waste stream samples at the required frequencies; and Failure to incorporate new scaling factors in a timely manner.

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The review included adherence to the PCP, accepted dewatering practices and controls in place to meet burial site criteria.

9.2.2 Findines

a. Nuclear Oversight identified the 10CFR61 compliance issues regarding resin processing. The Radioactive Materials Supervisor is knowledgeable concerning the issues Nuclear Oversight identified.

b. RPM 3.4-4 includes controls for the removal of freestanding water and addresses actions to be taken if an exothermic reaction occurs. The procedure has documented sign-off for dewatering duration.

c. The spent resin dewatering system has the capability to obtain a resin sample for 10CFR61 requirements. Procedure steps to assure that samples are obtained, analyzed, and the results are acceptable prior to filling the HIC are not included in RPM 3.4-4. Satisfaction of this requirement is dependent on the knowledge of the specific personnelinvolved.

d. The requirements in RPM 3.4-4 do not include a provision to obtain a 10CFR61 sample from the waste receiver tank. The supervisor is aware that, as plant conditions change, a sample will be required.

9.2.3 Conclusions

a. The sampling requirement for resin relies on designated personnel to recognize the need for the sample prior to filling the HIC. Procedure steps and sign-offs are not included in RPM 3.4-4.

9.2.4 Recommendations

a. Implement a check step in RPM 3.4-4 to verify that proper samples have been obtained and analytical results are acceptable for resin to be dewatered and shipped in the container.

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9.3 Training 9.3.1 Backaround The evaluation focussed on the training and qualifications of the Radioactive Materials Supervisor and the Radioactive Materials Handlers. Methods of maintaining this work force current with changing regulations, industry events, etc. were reviewed.

9.3.2 Finding

a. The training department maintains a training matrix for the Radioactive Materials Handlers. The Radioactive Materials department training program does not require INPO accreditation. The personnel presently involved in handling radioactive material have worked in the department for several years. The job scope of the department personnel has remained relatively constant. No issues were identified in training materials.

9.3.3 Conclusions

a. The training is adequate for the personnel currently filling the positions to performing the current job scope responsibilities.

b. Training requirements for procedure changes, industry events, etc. for the current group size of three (3) personnel and constant scope are easily managed through staffmeetings.

9.3.4 Recommendations

a. Develop a formal process for training of personnel for the major radwaste shipping evolutions that will occur during the decommissioning project. Training of essential personnel should occur at an early time within the project to allow for thorough radwaste input into the planning process.

b. Develop a formal process for training Radioactive Material Handlers ifincreasing their scope of responsibilities from the present routine workload.

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9.4 Shinoine 9.4.1 Background The shipping program was reviewed to determine methods of compliance with the burial site license and licenses of companies to which material is shipped.

Documentation from previous shipments was also reviewed.

9.4.2 Findings

a. Shipping manifests are being manually entered. The shipping manifest h manually completed by the Radioactive Materials Supervisor.

b. The current shipping procedures have a limited number of specific configurations that can be shipped. The assumptions used in calculations are applicable to those configurations only and are not clearly defined in the procedures. The Radioactive Materials Supervisor is aware of the limitations of the procedures.

9.4.3 Conclusions

a. Manual completion of shipping manifests is ineflicient and increases the probability of error. Commercially available computer software will improve quality and allow for the variations in material shipments anticipated during decommission.

9.4.4 Recommendations

a. Obtain a computer program for waste shipments.

9.5 10CFR61 Review l 9.5.1 Background This portion of the assessment included a detailed review of the following procedures in conjunction with interviews ofindividuals responsible for 10CFR61 compliance:

RPM 3.6-1, Shipment ofRadioactive Waste Packages, Rev. 9, dated 2/11/97; RPM 3.6-2, Radwaste Package Curie Calculations and 10CFR61 Calculation, Rev.

7, dated 2112/97; Page 87

RPM 3.6-3, Shipment ofNon- Waste Radioactive Material Packages, Rev.13, dated 1/21/97; RPM 3.6-4, Quality Assurance Programfor Radwaste Package Calculations, Rev. 5, dated 9/17/96; RPM 3.6-5, Use of the Radwaste Shipment Computer Program, Rev. 5, dated 3/21/95; RPM 3.6-6, Sampling Guidelinesfor 10CFR61 Compliance, Rev. 4, dated 1/24/94:

RPM 3.6-7,10CFR61 Scaling Factor Calculations and Implementation, Rev.1, dated 11/6/96.

9.5.2 Findings The activity of each isotope in a package is calculated manually. This method relies on dose rate to curie conversion factor charts (DRTC) developed by the Radiological Assessment Branch (RAB). The existing charts were developed for three shipping configurations: the LSA Box; C-Van; and filters. The assumptions used in the development of the conversion charts were:

1. The material in the configuration is a homogenous mixture.

2. The density of the mixture is uniform.

l

3. The shipping configuration is consistently filled to the same consistent fill level.

l The assessors noted that these assumptions were not included in shipping procedure l RPM 3.6-3. Rather, the practice is for the Radioactive Materials Handling Supervisor to recognize and flag any shipment that does not meet these assumptions. The Radioactive Materials Handling Supervisor then requests the RAB to develop a dose profile for the waste / material prior to shipping the package.

9.5.3 Conclusions

a. Procedure RPM 3.6-3 fails to specify the assumptive criteria that must be met in order to use existing dose rate to conversion factor charts.

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b. Procedure 3.6-3 does not contain guidance sufficient to prevent shipment of packages that fail to meet the assumptive criteria upon which the DRTC charts are based. Recognition that a particular package to be shipped fails to meet the assumptive criteria used in the development of the DRTC charts relies on the experience of the Radioactive Materials Supervisor.

9.5.4 Recommendations

a. Revise RPM 3.6-3 to include:

Definition of the assumptions used to develop DRTC charts.

Sign-offs to verify that the assumptions are appropriate for each shipment.

9.6 Process Control Proeram (PCP) 9.6.1 Backeround The assessors reviewed the Plant Technical Specifications with respect to the PCP and the Northeast Utilities Process Control Program Qualification Manual. The purpose of the PCP is a program statement concerning the process by which the plant is going to process wet waste in order to meet burial site criteria and meet shipping requirements:

l '"The Solid RADIOACTIVE WASTE TREATMENT SYSTEM shall be operated in l accordance with the PROCESS CONTROL PROGRAM to process wet radioactive

) wastes to meet shipping and burial ground requirements."

2" Written procedures and/or administrative policies shall be established implemented, and maintained covering the activities referenced below:

PROCESS CONTROL PROGRAM implementation."

3" Each procedure of Specification 6.8.1, and changes thereto, shall be reviewed by the Vice President - Haddam Neck prior to implementation and reviewed periodically as set forth in each document or in administrative procedures."

' Technical Specincation Section 6.14, pages 6-20 3

Technical Specification Section 6.8.1, pages 6-11

' Technical Specification Section 6.8.2, pages 612 Page 89

9.6.2 Findinas

a. The PCP is a corporate document that does not require plant approval. The plant implementing procedures address many issues that are not covered by the PCP but are required to assure compliance with burial site criteria.

b. The Radwaste procedures do not address the control of hazardous materials and chelates within the plant. Manifests require certification that the burial site criteria for chelates and other hazardous materials are met. Station control of these materials is through the Consumable Control Program. The Consumable Control Program is not referenced in the PCP, or the implementing procedures. Radwaste personnel responsible for waste shipment certifications do not sppear to be aware of the success or problems associated with the Consumable Contrcl Program.

c. The PCP does not contain provisions for evolutions expected to occur as part of the decommissioning process, i.e. full system decontamination.

f i

d. Radwaste procedures necessary to implement the PCP are appropriately reviewed and approved on site.

9.6.3 Conclusion

a. The provisions of the PCP as a single document do not address all programmatic aspects necessary to assure that the plant's wet waste will meet burial site and shipping requirements. Station procedures that address burial site requirements, not discussed in the PCP are necessary to assure full compliance with the burial site licenses.

b. Radwaste processing procedures do not address means of assuring that chelating agents and other hazardous materials meet the burial site requirements. There is not a defined interface between the Radioactive Materials Supervisor and the Consumables Control Program to provide positive evidence that the program is achieving its objective.

c. The PCP does not include provisions to control processes expected to occur during the decommissioning.

{

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9.6.4 Recommendations

a. The PCP should be revised to address control of activities planned for the decommissioning project. Revisions should include methods used to control hazardous materials and ch:lates at the plant,

b. Establish ties between the radwaste procedures and the Consumable Control Program to allow the Radioactive Materials Supervisor to gain positive assurance that hazardous materials and/or chelates have not had the potential for introduction into the wet waste processing system.

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10.0 RADIOLOGICAL OCCURRENCES 10.1 Backtround The assessors reviewed the CY provisions for the investigation of radiological occurrences.

The established program was compared with the guidelines ofINPO 91-014 to verify that a process was established and available for implementation. Aspects of this portion of the assessment included a review of applicable procedures and reviews of occurrence reports and related records. This assessment did not include an evaluation of the adequacy of the fmdings or conclusions of any specific reports.

10.2 Findinas 10.2.1 General Previously, two procedures addressed radiological incidents: RPM 1.1-1, RadiologicalDeficiencyIdentification and Trending, and RPM 1.1-l, Radiological Incident Notification and Reporting. Since the intent and content of these procedures were included in the stations Adverse Condition Reporting (ACR) system (procedure ACP 1.216.5, Adverse Condition Resolution Program Rev. O, dated 8/1/95), the two RPM procedures were canceled. The ACR process uses the 1 Action Item Tracking and Trending System (AITTS) to document ACRs, assign follow-up action, and to trend data. An improved query for data retrieval and presentation is currently under development.

Prior to 1997, the [formerly titled] Events Analysis Group was staffed with root cause-trained individuals who were on loan to the group from various departments station-wide. The group included an individual from the heath physics group whose focus was on health physics related events. Since then, the Group has been restructured and the CY employees were transferred from the stations. The reorganized function, now called the Corrective Action Department, is staffed with contractor personnel. Individuals in this group are responsible for performing the root cause analysis, preparing reports and closing events falling into the ACR system. The assessor noted that none of the individuals within the Department had health physics experience. I

(

l Root cause training is not, however, a requirement for conducting an ACR investigation. In light of this, the assessor held discussions with the Corrective Actions Department manager and health physics personnel to determine whether representatives from the HP Department participate in the investigations for ACR I

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events involving health physics issues. The assessor also reviewed reports of ACR issues involving the HP Department.

10.2.2 Tynes ofIncide'its Attachment 10 to Procedure ACP 1.2-16.5 lists radiological issues for which ACRs are to be prepared. The scope of the events appeared consistent with the guidance ofINPO 91-014.

10.2.3 Investientions and Investiention Reports The investigations focus on root cause determinations and address action to prevent recurrence. Interviews and critiques are included in the investigation and written reports are required.

The assessor reviewed the ACR files for issues involving the HP Department. The review indicated that the ACR procedures had been followed and health physics personnel were involved in the investigation, root cause determinatior and corrective action process for the individual issues.

10.3 Conclusiom l a. The CY ACR system provides a framework for documenting occurrences that is consistent with the guidance ofINPO 91-014 10.4 Recommendations l NONE l

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