ML20148B706

Insp Rept 50-312/88-07 on 880205 & 08.Findings of Rept Will Be Identified as Unresolved Pending Completion of Investigation.Major Areas Inspected:Response to Licensee 880204 Rept of Potential Exposure to Extremity of Worker

ML20148B706
Person / Time
Site:	Rancho Seco
Issue date:	03/03/1988
From:	Cillis M, Yuhas G NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V)
To:
Shared Package
ML20148B698	List: ML20148B694 ML20148B706
References
50-312-88-07, 50-312-88-7, NUDOCS 8803220092
Download: ML20148B706 (16)

See also: IR 05000312/1988007

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U. S. NUCLEAR REGULATORY COMISSION

REGION V

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Report'No. 50-312/88-07

Docket No. 50-312- '

License No. DPR-54

Licensee: Sacramento Municipal Utility Oistrict

14440 Twin Cities Road

,, Herald, California 95638-9799

Facility Name: Rancho Seco Nuclear Generating Station

Inspection-at: Clay Station and Sacramento, California

Inspection Conducted: February 5 and 8,1988

Inspector: 0. D Hs'kf

M. Cillis, Senior Radiation Speci list DatW Signed -

Approved by: 4. d . N '3 k[

G. P. Yuhas. Chief / Date Signed

Facilities Radiological Protection Section

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Summary:

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Inspection on February 5 and 8,1988 (Report No. 50-312/88-07)

Areas Inspected: Special unannounced inspection by a regionally based NRC '

inspector in response to the licensee's February 4,1988, report of a

potential exposure to the extremity of a worker in excess of the regulatory ,

limit. The purpose of the inspection was to determine if the licensee was

dedicating sufficient resources to evaluate the potential exposure, to verify

that the licensee was in the process of implementing additional measures to

control potential exposures from similar radiation sources, and to perform a

preliminary evaluation of the event. Inspection procedures 30703, 83729 and

93702 were addressed.

Results: The findings of this inspection will be identified as unresolved ,

pending the completion of the licensee's investigation related to this matter.

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DETAILS  :

1). Persons' Contacted

a). Licensee

'G. Carl Andognini, Chief Executive Officer, Nuclear

• J. McColligan, Director Plant Services-

• F. Kellie, Radiation Protection Manager

"R. Bowser, Radioiogical Technical Support Superintendent

~*S. Crunk, Manager, Licensing

• R. Jones, Licersing-

S. Nicolls, Radiation Protection Superint .cdent

J. Reese, Radiation Health Superintender.t

8. Rogers, Radiation Protection ALARA Specialist

P. Howard, Radiation ~ Protection Supervisor

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G. Hacket, Acting Radiation Protection Supervisor

D. Anderson, Radiation Protection Technician

• D. Le Gore, Quality Assurance Engineer

C. Helman, Radiation Protection Technician

W. Tearney, Acting. Radiation Protection Supervisor

b). Contractor Personnel

(1). Applied Radiological Controls, Inc.

C. Stewart, Senior Radiation Protection Technician

D. Pilkington, Senior Radiation Protection Technician

(2) United Energy Services

R. L. Baron, Health Physicist Supervisor

A. Kamrowski, Health Physicist

Denotes attendance at the exit interview conducted at the conclusion

of the inspection.

The inspector also met and held discussions with other members of the *

licersee's and contractors' staff.

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2. Background

On February 4,1988, at 11:56 a.m. (PST) the licensee made a report  :

pursuant to 10 CFR Part 50.72(b) of a potential exposure of 458 rem to

the back of a worker's lef t knee from a microscopic particle of Cobalt-60

estimated to be 43 microcuries (pCi). In response to the notification, a ,

Region V inspector was dispatched to the site on February 5, 1988, to

perform a preliminary evaluation of the event.

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The evaluation included interviews with the plant, technical (i.e.

corporate) and contractor staffs, reviews of selected surveys and air

sample data, licensee evaluations, selected procedures, Radiation Work

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Permits (RWPs), personnel expcsure and contamination reports, and l

statements obtained from involved licensee representatives. l

The examination revealed that the Chief Executive Officer (CEO), Nuclear, l

had requested the plant staff to devote whatever resources and talents

were necessary to assure that the evaluation of the potential exposure is *

completed in a timely manner. - The CEO requested his staff to develop an i

Action Plan for performing the ' evaluation. He requested that the Action l

Plan be ready for his' review by no later than February 10, 1988.

The licensee's initial response appeared to be consistent with the CE0's

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request. The worker's assigned skin dose had been reassessed and, as a

, result, had been changed from 458 rem to 523 rem. The licensee's staff j

stated that the 523 rem was a worst case estimate. The reviseo estimate

of 523 rem was based on a re-review of the actual time that the worker

had been in the area. i

A brief description of the event is as follows:

The worker had been assigned to weld into place a drain line on the "A"

} Decay Heat Removal (DHR) Pump which is located on the -47' elevation of

the auxiliary building. He had entered and exited the area on three ,

separate occasions. The first entry was made between approximately 7:00

p.m. and 11:30 p.m. on February 3,1988. A second entry was made between .

1:20 a.m. and 3:30 3.m. on February 4,1988. The final entry was made at ,

4:25 a.m. on February 4, 1988. The worker's final exit was made at  !

approximately 6:40 a.m. on February 4, 1988. It was during the worker's t

final exit that the microscopic particle, measured at 43 pC1, was found ,

on the backside of the knee of his left pant leg. The particle was  ;

determined to be on the inside surlace of his trousers. The worker had t

been found to be uncontaminated during the earlier exits that were made "

at approximately 11:30 p.m. , February 3,1988, and at 3:30 a.m. February i

4, 1988. The licensee concluded that the worker had picked up the hot

[ particle sometime during his last entry into the work area.

3. Chronology of Events

I. Introduction '

, The following code will be used to identify involved individuals for

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the text which follows: '

Radiation Protection Supervisors (RPS) - 1, 2, 3, etc. (i.e.  !

RPS-1, RPS-2) '

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, Radiation Protection Technicians (RPT) - 1, 2, 3, etc. (i.e.  :

RPT-1, RPT-2) l

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Worker 1, 2 or 3 (i.e. W-1, W-2, W-3)  !

For clarification purposes it should be noted that the worker f

receiving the potential high exposure will be identified as W-1 or I

Worke r- L.

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II. Sequence of Events

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a. RWP 88-075 was initiated on February 1, 1988. The RWP

authorized the_ repair of the "A" Decay Heat Removal Pump drain

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line. Average contamination levels were listed as 25,000-dpm

_per.100 square centimeters (dpm/100 cm2) while maximum levels

of contamination were greater than 1E6 dpm/100 cm2 The RWP '

required that contaminated surfaces in-the work area be covered

.with plastic sheeting or herculite. Protective clothing (PCs) '

consisted of a minimum of two pairs of coveralls, cotton and

rubber gloves (two pair) and shoe covers.

Radiation levels in the area were listed as 10-mrem /hr general

area with hot spot readings up to 800 mrem /hr.

The RWP required a full face respirator be worn for entry into

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a posted airborne area and for any operation involving.

decontamination, grinding, or welding.

The RWP specified that a Radiation Protection Technician would

be on call and would provide zone coverage while the work was ,

.in progress. ~

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The RWP did not require the use of process or other engineering

controls as a means of limiting concentrations of radioactive

materials in air or the spread of contamination.

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b. On February 2, 1988, it was determined that the drain line

would have to be replaced because attempts to repair it had

been unsuccessful. This was brought to the attention of RPT-1.

RPT-1 notified RPS-1 of the job scope change. RPS-1 decided to ,

wait for a change in the work request to come through before

evaluating the need for changes in the RWP. Subsequently,

RPS-2 working on grave shift was also made aware of the change

in job scope on the morning of February 3, 1988, at

approximately 1:30 a.m. RPS-2 reviewed the new work request

and decided that the existing RWP was adequate. He informed

the worker that presented him with the work request change that

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he felt the existing RWP was adequate. He did not inform

anyone of his decision, but annotated the work request to

require the workers to notify the radiation field office prior

to starting the work.

c. On day shift, February 3, 1988, the Radiological Protection

Technical Support Superintendent became aware of the job scope

change. The superintendent instructed her staff to establish

"Hot Particle Zone" controls for the work in accordance with

procedures in the licensee's Radiation Control Manual.. The

staff was asked to modify RWP-88-075 accordingly. This task

was assigned to RPS-3 and to the shift ALARA Technical Analyst

(ATA). The ATA and RPS-3 were not informed that RPS-2 had

performed a review of the new work request and therefore, they '

were not aware that RPS-2 felt that the RWP was adequate (see

paragraph II(b) above). RPS-3 and the ATA believed that they

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could change the RWP when the revised work request came through

the radiation protection (RP) field office. RWP 88-075 had not

been cancelled up to this point.

' Maintenance workers were assigned to cut out the drain line

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.during the afternoon of February 3, 1988. The maintenance

workers did not remember if they stopped by the radiation ,

protection field office to inform the radiation protection

group of their intentions to commence the work.

e. The valve was cut out at approximately 5:00 pm on February 3,

1988. The valve,-reading 350 mrem /hr on contact and 18 mrem /hr

~a t one foot, was placed on a piece of herculite to one side of

the Decay Heat Removal Pump. One end of the herculite was

pulled over the valve to cover it,

f. Dayshift RPT-3' relieved RPT-2 at about the time the drain line

was cut out. He notified the RP field office and informed the

ATA and the RPS-3 that the drain line had been cut out. RPT-3

was instructed to stop the job until a "Hot Particle Zone"

could be established. RPT-3 was also instructed on the types

of surveys to perform and to instruct the workers accordingly. L

RPT-3 established the "Hot Particle Zone" without conspicuously

posting the area as required by procedures AP 305-7, AP 305-8A

and AP 305-9 (see paragraph 4, herein); however, he did brief

the workers on his shift concerning how the zone was set up and

how they were to enter and exit from the area. RPT-3 made it

clear'to the workers that he would monitor the area, equipment

and them when they exited the work area. RPT-3 said he

subsequently provided his relief, RPT-4, with the same type of

briefing.

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A detailed radiation and contamination survey was performed by

RPT-3 at about 6:30 p.m. The survey report indicated that a

"Hot Particle Zone" had been established. The report indicated

that no particles were found on the workers or the tools. A

bag of trash reading 1500 mrem /hr on contact was removed from

the work area and taken to the waste compactor area for

packaging.

The contamination survey identified one swipe reading of 240

mrad /hr which was collected underneath the piece of herculite

(outer edge) that had been placed in the work area for the f

workers to lie on. General contamination levels in the work  !

area ranged from 2,000 to 50,000 dpm/100 cm2 There was no .

indication that any decontamination efforts had been made  !

during the work that was accomplished to this point.

g. A change of shift occurred at approximately 7:00 p.m. RPT-3 7

briefed RPT-4, stating that "Hot Particle Zone" controls had -

been established and relaying the instructions he had received  !

from the ATA. RPT-3 informed RPT-4 that continuous coverage of  :

the work had been established and that surveys of equipment and

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personnel exiting the area.were required. Workers 1, 2 and 3

showed up to continue with the replacement of the drain line.

h. .RPT-4 stated that, after being briefed by RPT-3, he provided

continuous coverage until the lunch break which was taken at

'approximately.11:30 p.m. RPT-4 said he informed W-1, W-2 and

W-3 that a "Hot' Particle Zone" was in effect.

'RPT-4' conducted-a contamination survey of the work. area and'of

-all three ' workers- and their tools prior to breaking for lunch.

Contamination levels in the work area were lower than. reported

in the survey performed at 6:30 p.m. No hot particles were

found on the workers or their tools. RPT-4 stated he informed

the three workers they- should notify him when they returned

from lunch. RPT-4 said he did not brief the workers as he had

been briefed by RPT-3.

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i. The three workers returned to'the work site at 1:20 a.m. on

February 4,1988, to complete the installation of the drain

line. The three workers exited the work area for a break at

approximately 3:30 a.m. and returned to complete the

installation of the drain line at about 4:25 a.m.

RPT-4 informed the inspector that he did not provide continuous

coverage for the' remainder of his shift, which concluded at

approximately 5:00 a.~m., because the workers did not inform him

when they returned to the work site at about 1:20 a.m.

However, the inspector noted that RPT-4 documented a radiation

survey performed on the Decay Heat Removal Pump at.2:00 a.m. on

the same morning and should have seen the workers in the area

after they had returned at 1:20 a.m.

RPT-4 informed the inspector that the valve discussed in

paragraph e., above, was seen lying adjacent to the pump;

however, at this time it was not contair.ed in any wrappings.

He stated that he bagged the high reading valve and set it

aside. RPT-4 felt that the valve may have been the source of

the hot particle which was subsequently found on W-1.

RPT-4 was relieved by RPT-5 at approximately 5:00 a.m. RPT-4

informed the inspector that he failed to brief his relief

during the turnover as he had been briefed the evening before.

The inspector was unable to determine the reason for the

discrepancy in the statements obtained from RPT-4 because he

had subsequently terminated his employment as a contract RPT.

Discussions with the licensee's staff disclosed that they also

received some conflicting statements from RPT-4 which they may

not be able to clarify.

W-1 informed the inspector that he did not remember being told

of the "Hot Particle Zone" or being requested to contact RPT-4

-before returning to work at 1:20 a.m. The inspector did not

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get the opportunity to pose the same question to Workers 2 and

3 during the' inspection,

j). Workers 1, 2 and 3 had exited the work area at 3:30 a.m. and

had. returned at 4:25 a.m. Worker 1 stated that he and.the

other.two workers had performed a whole body: frisk at the

control point exit located <on the +40' elevation of the

. auxiliary building. Worker 1 stated that no contamination was

detected by.the PCM-1B monitor during the earlier exit of 11:30

p.m. on Februar) 3, 1988, or the 3:30 a.m. exit of February 4,

1988.

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Worker 1 added that he and his coworkers were not monitored by

RPT-4 prior to exiting at 3:30 a.m.

k). Workers 1, 2 and 3 returned to the job site at approximately

4:25 a.m. Worker 1 stated that-he completed the installation

of the drain line, and approximately one half hour prior to

exiting one of his coworkers left the work area to notify RPT-5

that they were exiting. They. requested that RPT-5 come down

and survey them and their equipment. Worker 1 stated that

there was no telephone located in the work area so his coworker

had to go up to the -20' elevation to make the call.

Worker 1 added that he and his coworkers cleaned up the area

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and after waiting for approximately 15-20 minutes for RPT-5 to

show up they decided to leave.

Worker 1 said that he had seen an additional step-off pad (S0P)

in the area, but did not understarcd why it was there. He added

that he was not made aware of any special undressing procedures

that had to be followed. He also said that he exited the area

as he had at 11:30 p.m. on February 3 and again at 3:30 a.m. on

February 4, 1988. Worker 1 said that he left the -47'

elevation with a pair of tennis shorts and tennis shoes. Upon

arriving at the -20' elevation personnel frisking station he

attempted to frisk himself with an Eberline, Model RM-14

frisker equipped with an HP-260 pancake probe. He said that he

observed an abnormal count or high background. His coworker

checked out with no abnormal measurements.

Worker 1 said that he then proceeded to the grade elevation of

the auxiliary building where he attempted to frisk himself

again with another RM-14 survey meter. He said that he got the

same response from the meter so he decided to don his blue

jeans and a shirt that were in a locker, located adjacent to

the personnel frisking station. He added that his coworkers

checked out clean. It should be noted that Worker 1 did not

perform a whole body frisk. He had only performed a cursory

check of his upper torso (above the belt line) during the frisk

he performed on the -20' and grade elevations.

The inspector asked W-1 why he and his coworkers didn't attempt

to call RPT-5 and/or the Shift Supervisor 's required by

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licensee procedure AP 305, Article 2,'Line Item No. 18. The

inspector added that specific instructions consistent with Line

No. 18 are provided in the General _ Employee Training (GET)-

program which W-1 had last attended on March 3, 1987. The-

inspector also.added that telephones were available on the -20'

and the Grade . elevations .of the auxiliary building. The

Einspector concluded by stating that'RPT-5 had no.way of knowing

.whether W-1 may have been contaminated at that time. Worker 1

stated that they-had already waited 20-30' minutes for,RPT-5 to

'show up and since RPT-5 'didn't respond. to their earlier call,

he decided to leave. -The inspector reminded W-1 that the

' status had changed such that'there.was an indication that he

may have been contaminated and therefore another call should

have been made for<RPT-5 or the Shift Supervisor.

. Worker 1 said after. leaving the grade level he proceeded to the

control' point exit on the +40' elevation at which point the

PCM-1B Eberline gas proportional monitor began to alarm when he

was 3 to 4 feet away. Workers 2 and 3 had checked out clean.

The RPTs at the control point determined after about one-half

hour that Worker 1 had a particle on the inside of his trousers

in the area of the knee of his left leg.

The particle, which was later identified as 43 pCi, Cobalt-60,

was measured with an Eberline R0-2 survey meter. The readings

were:

1600 mrads/hr - Beta

27 mrem /hr gamma

0.6 mrem /hr @ 1 foot gamma

It should be noted that RPT-5 who came on shift at 5:00 a.m. on

February 4, 1988, stated that he had not been briefed by RPT-4

about a Hot Particle Zone being in effect. He said RPS-3

mentioned that a "Hot Particle Zone" was established in the

pump room and was shown a copy of the survey report documented

by RPT-3 after the 6:30 p.m. survey was performed. He added

that the survey report did not clearly define the hot particle

zone. RPT-5 said he inspected the area at the beginning of his

shift and had concluded that the "Hot Particle Zone" was not in

the area where Workers 1, 2 and 3 were working; therefore, he

did not provide continuous coverage for the work that was

performed between 5:00 a.m. and 6:40 a.m.

RPT-5 said the Hot Particle Zone was not conspicuously posted

and it wasn't made clear to him exactly where it was by RPS-3.

RPT-5 said that he did not immediately respond to the workers'

request for a personnel survey because he was not aware that he

was required to monitor them prior to exiting or that Worker 1

was potentially contaminated.

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RPT-5.did make'one entry during the shift to perform a

~ radiation measurement at which time he adjusted some of the

radiation area hot spot postings. The survey was taken with a

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-minimum of protective clothing which consisted of shoe covers

(plastic flats) and cotton and rubber gloves even though the

area was classified as a "Hot Particle Zone" on the survey

report taken at 6:30 p.m. ,_ February 3,1988.

4. Controlling Documents

a. Procedures-

The;following procedures from the licensee's Radiation Control

. Manual were reviewed:

Procedure No. Title Revision Date

AP.305 Radiation-Control Manual Rev. 20 10-31-87

RP.305-4 Radiation Work Permits Rev. 0 12-09-87

RP.305-7 Area Definitions and Posting Rev. 0 12-29-87

RP.305 8A ' Routine and Radiation Work Rev. 0 12-02-87

Permit Surveys

RP.305-9 Contamination Limits and Rev. 0 12-22-87-

Control for Plant Surfaces

b. Observations

(1) AP-305-4, paragraphs 6.2.8, 6.2.10 and 6.2.10.9 and AP 305-9,

paragraph.6.2.3.1 state in part:

Paragraph AP 305-4

"6.2.8 Using the job description, radiological-conditions,

as determined from the survey, and the ALARA Group

recommendations, determine the requirements for

. protective clothing, engineering controls,

respiratory protective equipment and dosimetry (refer

to Enclosure 8.4 for Protective Clothing Selection

Guidelines)."

"6.2.10 In determining the protective clothing requirements

and any special instructions pertinent to the work

being done, the following items should be

considered...."

"6.2.10.9 If planned work involves the opening of a system,

it may be necessary to wait until the system is .

opened to determine maximum contamination or airborne

radioactivity levels. Full protective clothing and

full face respirator are the minimum requirements for

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opening-a primary system because of concern for beta

dose and hot particles, unless containments isolate

the worker ~from the open system."

-AP 305-9

"6.2.3.1 'For-jobs with high potential for spreading

contamination it.may require use of containments,

tents-or work enclosures, and HEPA filters (per

RP.305-31). Normally, the group performing the work

will beiresponsible for setting up a_ containment,

which is then inspected by RP personnel. General use

'HEPA filters units _are available from RP. Special

applications like asbestos work or RCP pump

replacement may require a dedicated HEPA provided by

the work group in accordance with RP guidelines."

Finding: The use of engineering controls as is recommended by

10 CFR Part'20.103(b)(1) and the above licensee

procedures for minimizing airborne radioactivity

levels were not prescribed for the initial and

subsequent work that was accomolished during the

. repair and/or removal of the drain line. The

licensee does maintain-a supply of controlled vacuum

cleaners and portable exhaust units equipped with

HEPA filters which, if utilized, could have prevented

the spread of contamination and/or hot particles.

Finding: RWP 88-075 did not provide precautions to indicate

the potential for Hot Particles when the system was

opened.(see' paragraph 6.2.10.9)

(2) AP 305-8A, Section 5 states in part:

"5.0 PRECAUTIONS

"5.1 Hot particles represent a significant problem in

detection and control. When found or suspected;

immediately notify the Rad OPS Supervisor and perform

the following:

"5.1.1. The area will be posted per RP.305.7 and access

controlled by RWP.

"5.1.2 Hot particles will be bagged and submitted for

isotopic analysis, unless otherwise directed by RP

Supervision.

" 5.1. 3 Large areas (maslin) contamination surveys should be

conducted on surfaces in the area of discovery.

" 5.1. 4 All protective clothing used in the area will be

segregated, and surveyed in detail for additional hot

particles prior to being sent out for laundry.""

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AP;3b5-7,. Section 6.7 states in part:

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Hot Particle Zo'ne

"6.7.1 ' Hot-Particle Zones must be conspicuously posted as a

Contaminated Area per-6.6 and with a Hot Particle

Zone sign.

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"6.7.2- Entry into a Hot Particle zone requires an RWP and

continuous Radiation Protection coverage.

"6.7.3 Double Step-Off Pads are required to be established

at the exits from these areas.

"6.7.4 Personnel exiting these areas are required to be

surveyed to ensure they are free of hot-particles ""

and AP 309, Section 6.7 states in part:

"6.7 Hot Particle Control Requirements

When hot particles are found or suspected, an RP Tech

will:

"6.7.1 Post the area, report to RP Supervision and control

access by RWP.

"6.7.2 Bag and label the hot particle (s) in accordance with

RP.305.9A, and submit for isotopic analysis unless

otherwise directed by RP Supervision.

"6.7.3 The RP Tech will escort the hot particle (s), unless

. directed otherwise by RP Supervision.

"6.7.4 Conduct large area (maslin) contamination surveys on

surfaces in the area of discovery and the transfer-

routes.

"6.7.5 Segregate all protective clothing used in the area.

Notify Radwaste Supervision. Survey in detail for

additional hot particles prior to sending out for

laundry.

"6.7.6 Store and dispose of hot particles as directed by

Radwaste Supervision."

Finding: Continuous coverage as required by AP 305-7 was not

provided after the "Hot Particle" program had been

established at the request of the ATA.

Although the area was designated as a Hot Particle

Zone, RPT-3 stated that it was not conspicuously

posted with barriers and signs to clearly define it

to personnel working in the area.

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, . The examination disclosed.that personnel working on.

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the same shift as RPT-3 were briefed on the

requirements: for working in the "Hot Particle : Zone";.

however, the examination.also disclosed that RPT-4

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faile'd.to properly brief Workers 1, 2, or 3 and RPT-5.-

on the "Hot Particle Zono" and how to~ control

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activities,in the area. -Workers'1, 2, and 3 informed

'the. inspector.that they exited from'the area as they

. normally would; however; if so instructed:they would

have' removed the first pair of. protective clothing at*

. the first step off: pad-(SOP) and the second set at

'. the second SOP.

RPT-5 also stated that he was not sure where the "Hot

Particle Zone" was because it wasn't conspicuously

posted.

RPT-4 informed the inspector that he failed to give

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the workers and RPT-5 a good briefing.

The hot swipe (i.e. 240 mrads)~ obtained by RPT-3 was

not bagged and submitted for. isotopic analysis as

required by AP 305-8A and AP 305-9.

Personnel and equipment were not surveyed after 11:15 :

p.m. February 3, 1988. The only surveys performed

after 11:15 p.m. were a hot spot survey at 2:00 a.m.

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and a' general area survey at approximately 5:30 a.m.

February 4, 1988.

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(3) The inspector noted that the procedures related to the "Hot

Particle Zone" control program do not provide instructions

concerning the criteria to be applied by RPTs for suspecting

when they have a Hot Particle problem. The inspector asked

RPSs 1, 2, 3 and 4 and RPTs 1, 2, 3, 4 & 5 if they knew how to

determine if there was a Hot Particle problem. One RPT stated

that he had received some training at another utility company

related to Hot Particles and fuel fragments. The others did

not know exactly how to make the determination (see Report

Section 5).

(4) Paragraph 6.2.2.1.3 of AP 305-8A prescribes the frequency for

performing routine and RWP surveys. Paragraph 6.2.2.1.3.2 of

the procedure requires that surveys be performed to monitor

changing conditions. Paragraph 6.2.3 of the procedure states

in part'that for some evolutions, this may mean performing

several surveys in one day.

Finding: A review of surveys for the work performed between

5:00 p.m. February 3, 1988, and 7:40 a.m. February 4, 1988,

revealed that surveys taken af ter 11:15 p.m. , February 3,1988

did not include contamination surveys of the work area or of

the equipment and personnel and therefore could not have

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identified whether-the contamination or Hot Particle problems-

identified from the earlier surveys had changed,

f. Training and Implementation of Information Notices (ins)

The inspector examined the current status of RPTs and workers training

related to the following areas:

' General Employee's Training (GET)

IN 87-39, "Control of Hot Particle Contamination at Nuclear Power

Plants"

IN 86-23, "Excessive Skin Exposures due to Contamination with Hot

Particles"

The Radiation Protection Manager provided the inspector with copies _of

correspondence providing information on the licensee's plans for the

implementation of IN 87-39 and 86-23.

Through discussions and a review of training attendance records, the

inspector determined that the Hot Particle training for RPTs was not

scheduled for completion until June 1988. Only a portion of the training

had been provided. The RPM stated there had been numerous meetings

discussing the implementation of IN 87-39 and 86-23. He added that it

was decided to provide the training of workers and RPTs in stages. The

first stage was attended by all RPTs except for RPT-4; however, the

inspector ver'1fied that RPT-4 had read all controlling documents related

to the "Hot Particle Zone" control program.

Discussions held with the Training Supervisor revealed that the Hot

Particle Training Program was phased into GET on October 10, 1987. The

phase-in has been gradual and has been updated on two or three occasions

since then. The most recent. update of the GET program was made on

February 1,1988. Worker 1 had not attended GET since March 3, 1987;

therefore, he had no exposure to the hot particle training program

provided in the GET program. One of the two workers that worked with

Worker 1 had attended a later GET class that was presented on January 5,

1988. This class provided attendees with a general overview of IN 87-39

concerns. The class did not discuss "Hot Particle Zone" control.

The Radiation Protection Manager stated that a SMUD staff member had

attended workshops conducted by counterpart utility companies located in

Region V area and that he has dispatched a staff member to a Region V

utility company following this event. The RPM added that the utility

company had an established hot particle program which will be considered

for use at SMUD. The RPM went on to state that the hot particle training

program would now be scheduled for completion at an earlier date than *;as

originally scheduled.

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6. Other-Licensee' Actions /0bservations

a. Other Licensee' Actions

.The inspector noted that the licensee had taken or were taking.the

following actions:

The involved worker was sent to University of California

. Medical Center for an examination by a Nuclear Physicist and

physician.

Arrangements were made for obtaining bioassay samples from the

worker.and to: schedule the worker for a whole body count.

, The hot particle.and the worker's protective clothing were

saved. The licensee's staff planned to survey the worker's PCs

to see if any useful information can be obtained. They also

intend to send the Hot Particle to an offsite laboratory for an

independent analysis. The~ staff also plans to evaluate where

the particle was on the worker's jeans (i.e. inside or

outside).

A Standard Test Procedure (STP) was being developed to run a

mockup of the event. The purpose of the mockup will be to

determine when the Hot Particle was transferred to the worker's

trousers. The licer see staff uindicated there was the

possibility that the Hot Particle was lodged on the worker's

shoe when he exited the work area at 6:40 a.m. on the day of

the event. The staff added that the worker may have

transferred the hot particle from his shoe when he put on his

trousers while on the Grade Level. The Hot Particle will be

used in an attempt to duplicate the abnormal readings

experienced by Worker 1 when he frisked himself on the -20' and

Grade level of the auxiliary building. . The coworkers that

exited with Worker 1 will be asked to witness the tests to

ascertain whether the background levels experienced by Worker 1

are identical to those of February 4, 1988.

Interviews with the involved workers were ongoing at the time

of this inspection. Statements obtained from individuals were

being reviewed for conflicting data.

_

Worker l's thermoluminescent dosimeter (TLD) was processed.

The TLD showed that the worker received a whole body dose of

105 mrem. This was consistent with the dose measured by the

individuals pocket ionization chamber (PIC), which showed 100

mrem. No shallow dose (beta) was reported.

Detailed followup surveys (i.e. radiation and contamination) of

the workers' exit route and clothing lockers were performed.

Plo abnormal measurements were reported.

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b. Other'0bservations

A review ~of security records and-dosimetry records for the

period of = February 1,1988, through February 4,1988, disclosed

that the Radiation Protection Superintendent and staff of three

RPSs identified in this report had not visited the job site.

• - Internal communication for involved personnel within the

Radiation Protection group'was poor. There was-inattention to

detail. The inspector expressed some concern about the

decision reached by RPS-2 when.he determined that RWP 88-075

was adequate after the job scope had changed. The decision was

not consistent with the guidelines in AP 305-4, paragraph

6.2.10.9 and what was subsequently ^ decided by the Radiological

Protection Technical Support Superintendent (see paragraph

3(c)).

This matter (Report Sections 2-6) is considered unresolved (88-07-01).

Unresolved items are matters about which more information is required in

order to ascertain whether they are acceptable items, violations or

deviations.

7. Exit Interview

The inspector met with the licensee representatives (denoted in

paragraph 1) at the conclusion of the inspection on February 8, 1988.

The scope and findings of the inspection were summarized. The inspector

stated that the single, most significant contributing factor associated

with the event was failure to comply with controlling procedures,

particularly AP 305-7.

The inspector said it may never be determined with any degree of

certainty how and when the hot particle was deposited on the worker

because Worker 1 failed to comply with the instructions every worker

receives as part of GET and as required by AP 305, Article 2, Line Item

18. The-inspector added that-factors contributing to the event were:

a. Failure of RPT-4 to perform his job and adequately brief the workers

and RPT-5 that a "Hot Particle Zone" had been established,

b. Failure to complete the Hot Particle Training program for workers

and RPTs.

The inspector added that there were missed opportunities that could have

mitigated the event, such as:

Failure to cancel RWP 88-075 when it was first learned that the

scope of the job was to change. The Radiation Protection staff was

made aware of the change two days before the event occurred.

Failure to provide appropriate supervision.

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The poor communications within the Radiation Protection group.

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Worker l's. failure to call for radiation protection assistance-at'

'the -20' or the grade elevation of the auxiliary building.

Failure of worker 1 to perform an adequate whole body frisk on the

-20'~and grade elevations.

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RPT-5's failure to respond to the call for a survey in'a timely

manner.

The inspector concluded by stating that the findings of this inspection

will'be identified asiunresolved pending the completion of the licensee's ,

evaluation and submittal of their 30 day 10 CFR Part 20.405 report.

The inspector added that a special inspection will be scheduled upon

receipt of the 10 CFR Part 20.405 report.

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