ML20197A850
| ML20197A850 | |
| Person / Time | |
|---|---|
| Site: | Wolf Creek  |
| Issue date: | 12/12/1997 |
| From: | Warren C WOLF CREEK NUCLEAR OPERATING CORP. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| 50-482-97-20, WO-97-0133, WO-97-133, NUDOCS 9712230225 | |
| Download: ML20197A850 (9) | |
Text
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s WeLF CREEK NUCLEAR OPERATING CORPORATION cier c. wonen cn.# os reting oftw i
l 1
December 12, 1997 UO 97-0133 l
1 U. S..Iluelear Regulatcry Commission Mail Station F1-137 ATTN Document Control Desk Washington, D. C.
20555 a
r Reference Letter dated tJovember 14, 1997, frem A. T. Howell III, l
NRC, to 0. L. Maynard, WCt10C
Subject:
Docket No. 50-402:
Response to Notice of Violations 50-482/9720-01, 9720-02, and 9720-03 l
Gentlement This letter transmits Wolf Creek Nuclear Operating Corporatton's (WCNOC) response to Notice of Violations 50-482/9720-01, 9720-02, and 9720-03.
Vio.$ation 9720-01 cites a failure to post and control a locked high radiation areas Violation 9720-02 addresses a failure to track and label items i
containing radioactive materials and Violation 9720-03 identifies a failure to conspicuous)y post a contaminated area.
WCNOC's response to these violations is provided in the attachment.
If ycu have any questions regarding this response, please contact no at (316) 364-8831, extension 4485, or Mr. Michael J. Angus at extension 4077 t
Very truly yours,
< m Clay C. Warren V CCW/jad Attachment cel W. D. Johnson (NRC), w/a E. W. Merschoff (NRC), w/a J. F. Ringwald (NRC), w/a
}J K. M. Thomas (NRC), w/a
\\
9712230225 971212 i
t i,
i * *
- PDR ADOCK 05000482 O
PDR P.O. 00m 411 i Durkngton, K$ (4839 i Phone: (316) 364 8831 An f qual Opt.aw,y t%w M F HOVtT
Attachment to WO 97-0133 Fogg 1 of 8 Violation 50-402/9720-01:
"10 CFR 20.1003 defines a high radiation area as an area, accessible to individuals, in which -radiation levels could result in an individual receiving a dose equivalent in excess of 100 millitems in 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> at 30 centimeters from the radiation source or f rom any surf ace that radiation penetrates. 10 CFR 20.1902(b) requires the licensee to post a high radiation area with a conspicuous sign or signs bearing the radiation symbol and the words, ' Caution, high radiation area.'
Technical Specification 6.12.2 requires, in part, that areac accersible to personnel with radiath of greater than 1000 millirems per hour shall be provided with doors to prevent unauthorized entry or, where no enclosure existr.or the purpose of locking and no enclosure can. be reasonably constructed around the indivrdual
- area, that individual area be barricaded, conspicuously ported, and a flashing light shall be activated as a warning device.
Contrary to the above, October 12-13, 1997, an area above filter FHD11 with radiation levels grmater than 1000 millirems per hour was not conspicuously posted as a high rtdiation area and a flashing light was not activated as a warning device."
Reason for Violetion:
During routine replacement of the THbil filter, the work was stopped due to a broken cover bolt (one of four).
At shift turnover, the job was lett for the oncoming crew to replace the broken bolt, once an engineering disposition was received, and then to continue with completioa of the filter change-L t in accordance with the work package.
The oncoming crew supervisor was directed by Outage Cor.t rol Center personnel to torque the three bolts, so the system could be returned to service.
The decision was based on the need to support Refuel Gutage IX activities.
Maintenance personnel tightened the three bolts, and signed off the work package as complete, with annotations by the supervisor that only threa bolts were tightened, and that WCHOC Operations perscnnel would ret. lace the Shield plug.
The unit was leak tested and placed in service at 2:30 AM on October 13, 1997 At approximately 1'00 PM on October 13, 1997, it was discoveted that the shield plug had not been replaced. Thia condition went undetectad, and the radiation levels began increasing _ af ter the filtration unit was (Aaced into service.
Dose rate gradually increased until the condition was diocovered, approximate.y ten hours later.
Dose rates at that time were found te be ten REM per nour on contact, and three REM per hour at twelve inches.
This condition had the potential to cause significant personnel radiation e,cpesure; however, no significant exposure was recorded because of the event.
Root Cause:
The roct cause of this event was failure of individuals to follow tue requirements of maintenance procedure MCM M7230-01, Revision 9, "NSSS Filter Changeout."
' Attachment to WO 97-0133 Page.2 of 8 Contributinglaetors The following causal factors -contributed to the failure to follow the requirements of-procedure MCM M7230-01.
A Maintenance past practice of allowing individuals outside the Maintenance department to complete procedure work steps for them.
- A failure of Maintenance personnel to adhere to the administrative requirements of procedure AP 15C-002, " Procedure Use and Adherence."
i e A failure by the individuals involved to consunica t e the need for actions to assure the work was completed in a satisfactory manner.
Corrective Steps Taken and Results Achieved:
- When the condition was identified, the Shift Supervisor, Health Fhysics Shi Technician, and Health Physics Supervision were insediately informed.
Hom_th Physics personnel surveyed and posted the area, then secured the area by having the shield plug renlac.1.
Procedure GEN 00-030, Revision 16, " Solid Radwaste System Filter Change" was revised on October 14, 1997, to add specific direction to operators for installj ng the shield plug.
- On December 4,
1997, procedure MCM M7230-01 was revised by on-ie Spot-Change (OTSC) 97-0829, to cover only the steps which Maintenance personnel perform.
- The Superintendent Chemistry / Radiation Protection reinforced management expectations regarding communications with Health Physics personnel during a two hour stand down period on October 14, 1997 This session included both in-house and contractor technicians.
The Superintendent Chemistry / Radiation Protection emphasized the need to apply focus on work expectations, to be intrusive, and to demand to be notified of system changes.
- On October 14, 1997, the Superintendent Chemistry / Radiation Protection also gave direction to the Health Physics organization to not allow the filter shield plugs to be removed, in the future, without continuous Health Phyt' coverage.
Administrative Procedure AP 25A-200, " Access to Locked High Ver y High Radiation Areas" was revised on November 18, 1997, to reflect this direction.
- On November 6,
- 1997, the Manager Maintenance gave training to all M4!ntenance Supervisors and workers, to reinforce:
J't procedures must be followed, even if told something different;
- 2. That workers should never allow anyone in authority to give direction which would cause a violation of procedures;
- 3. That workers should never allow another organization to perform work you are responsible to perform;
- 4. That supervisors are allowed to annotate steps not performed in a procedure only if not performing the step has no affect on the outcome of the work activity; and,
'Attachm:nt to WO 97-01J3
- Pag 2.3 of 8.
$. The need for better communications when exceptions to routine activities are encountered.
Corrective Steps To Be Taken:
A supplement to Performance Improvement Pequest (PIR) 97-3199 will be developed to - document the actions taken t clarify the requirements for placing non-conforming-equipment into servi, s.
This clarification will be communicated to site personnel by February 1, 1998.
Date When Full Compliance Will Be Aphiev6d1
-At approximately 1100 PM cn Oc cber 43, 1997, it was discovered that the shield plug had not been replace.
The area was immediately surveyed by Health Physics, and proper po. tings established.
This posting re-established compliance to 10 CFR !0.1902(b) and Technical Specification 6.1 2.2 on October 13, 1997.
' Attachment to to 97-0133
..4 Page.4 of 8 Violation 50-482/9720-02:
" Technical Epecification 6.8.1.a
- requires, in
- part, that written procedures be established, implemented, and maintained covering the procedures recommended in Appendix A of Regulatory Guide-1.33, _ Revision 2,
February 1978.
Section 7.e. (4) lists radiation protection procedures for contamination control.
Procedure RPP 02-515, 'Releass of Material From the RCA,'
Revision 8, Section 9.4.1 states, in wrt,
' Material fjoT meeting the unconditional release criteria may be ta Mr. outside the normally established RCA.
Form RPF 02-515-02 is used for evnditional release of items.'
Section 9.4.1.d states, in part, "The item must be labeled.
Contrary to the above, Snubb3rs 17994 and 20231, items not meeting-the unconditional release criteria were taken outside the normally established radiological controlled area on October 12, 1997, without using Form RPF 02-515-02 and without being labeled to identify the presence of radioactive contamination."
Reason for Violation On October 12, 1997, a Health Physics technician conditionally released two snubbers from the Radiologically Controled Area (RCA) using form RPF 02-210-1,-
"WCGS Radiological Survey Map."
The correct form for conditional release of material from the RCA is RPF 02-515-2,
" Conditional Release Form."
Investigation identified that the individual received a call from the Health Physice Shitt Technician with information that two workers would be needing snubbers released from the RCA.
The snubbers were to be installed in Area 5 (main steam enclosure; which is normall" a part of the RCA, but had been temporarily released f rom the RCA to support main steam isolation valve work for Refuel Outage IX.
The correct procedure, RPP 02-515, Revision 8,
" Release of Material from the RCA," was provided to the individual by ;he Shift Technician, and the individual was told to release the snubbers if t' ey were radiologically acceptable.
Upon surveying the snubbers the individual was able to detect 40 counts per minute by direct frisk, which meets the criteria for unconditional release.
Because there were areas not accessible to survey,.the individual chose to be cor.servative and leave the radioactive material stickers on the snubbers, and release them conditionally.
The snubbers were transported tc Area 5 and in9talled in their permanent location.
Area 5 has since been returned to its norual status as part of the RCA.
All survey conditions required by form RPF 02-515-2 were performed and documented in a retrievable form on the Radiological Survey Map; however, not using the correct conditional release was contrary to procedure RPP 02-515, Revision 8,
" Release of Material From the RCA."
The release of equipment, without using the proper form, increases the potential to lose accountability and documentation of the equipment regarding destination,
- owner, Health Physics requirements for the return of the item, and acknowledgment of the item's return.
Even though the decision to conditionally release these snubbers was conservative, and not required, the correct form should have been used.. The correct form, RPF 02-515-2, was completed upon identification of the fact that the incorrect form was used.
Root Cause The root cause for this incident was inadequate work practice, as evidenced by
-the individual involved not following procedural direction for conditionally releasing equipment from tne RCA.
This was demonstrated when the individual
'Atttchm:nt to WO 97-0133 Pega 5 of 8 used a survey map to document the radiological conditions of the conditionally released equipment-instead of the Conditional Release-Form RPF 02-515-2.
Corrective Steps Taken and Resulta Achieved:
- A fact finding investigation has been performed for the event.
The appropriate disciplinary actions have been completed.
+- The Health Physics technician responsible for the incident was counseled that RPF 02-515-2 is the correct form to use when performing conditional release of tools and equipment from the RCA, and'was required to fill out the correct form.
Corrective Steps To Be Takon:
fio furt!.or corrective actions are necessary.
~ Date When Full Comr,liance Will Be Achieved:
Full compliance was achieved on October 24, 1997, when the correct RPF 02-515-2 form was completed.
At that time, the two snubbers (17994 and 20231) were correctly controlled and documented, as required by procedure RPP 02-515, Revision 8,
" Release of Material From the RCA."
'Attdchment to WO 97-0133
- Page 6 of 8 Violation 50-482/9720-03:
" Procedure RPP 02-215,
' Posting of Radiological Controlled Areas,'
Revision 11, Section 9.1.1 states, in part, ' Area Postings are shown in Attachment A.'
Attachment A of the procedure requires that an area be posted if contamination levels are equal to or greater than 3000 disintegrations per minute per 100 centimeters squared (beta / gamma).
Section 9.1. 2 states, in part, ' Posted areas must be clearly and conspicuously marked at all accessible sides and entrances.'
Contrary to the above, on or about August 7, 1997, an area arcund the spent fuel pool with contamination levels equal to or greater than 1000 disintegrations per minute per 100 centimeters squared
-(beta / gamma) was not conspicuously marked on all accessible sides."
Reason for Violation:
On August 5, 1997, while performing an investigation survey for personnel who had become contaminated while in the clean area around the work area, i' was noted by the contract Health Physics Technicians covering the work, that the workers were grabbing the boundary rail as they used the ladder for access into and out of the transfer canal.
This had caused at least two personnel contaminations to the " clean" area.
This contamination has radiclogical safety significance because the area around the Spent Fuel Pool is posted as a Potential Hot Particle Area, with the pool itself being posted as a Hot Particle Area.
To remedy the condition described above, a herculite boundary was raised by approximately one foot on the outside of the handrail.
When the additional horculite was installed, the strap, which is sewn to the permanent herculite rail covers to allow for hanging a Health Physics posting, was covered over after the posting was removed.
After completing the addition of the extra herculite the Health Physics Technician (s) failed to re-hang the posting, believing that the remaining postings around the area met the requirement for "conspicuousiy marked."
On Thursday, August 14, 1997, Health Physics was notified by a resident NRC inspector that the radiological postings around the Spent Fuel Pool on 2047' elevation of the Fuel Building did not meet the " conspicuously marked" requirements of RPP 02-215.
His concern was that there was no Health Physics posting for the Spent Fuel Pool area in a direct line of site as he entered the 2047' elevation of the Fuel Building from the 2047' elevation of the Auxiliary Building.
A proper posting was hanging approximately ten to twelve feet further down the railing, and on each of the rail secticns around the pool area.
There is no set maximum distance requirement f^r posting in the WCNOC Health Physics procedures, and.the " conspicuously marked" requirement is subjective.
All the hand rails which surround the Spent Fuel Pool area are also covered with herculite covers, thereby forming a ~ barricade around the area that prevents
. inadvertent entry into the area.
During the planning phase of this job, the Site ALARA Committee determined the need for an in-house Health Physics Technician to be assigned to this work to promote better communications between the work groups and Health Physics, and to ensure-procedural compliance by the contract Health Physics Technicians
'Attcchmsnt'to Wo 97-0133
- Peg:.7 of 8 This requirement was noted in Attachment 1,Section IV of the Pre-Job ALARA Brief, but was not clearly stated.
Because of the unclear requirement and Health Physics staffing versus work load considerations, continuous coverage by in-house technicians was not accomplished.
Multiple in-house Health Physics Technicians were rotated through the job as their shift rotation and other work load allowed, which did not allow for a in-house Health Physics Technician to be there every day.
Minimal "in the field" support or direction by WONOC Health Physics supervision was givenuto the workers on this job.
Although Health Physics supervision did attend the daily morning briefings that were held in the Health Pnysics/ALARA Briefing Room at Access
- Control, Health Physice supervision was unable to monitor the work in the field on a regular basis.
It was also noted at this time, that the Health Physics Supervisor Operations has a large administrative load, which is directly related to the very large worker to supervisor ratio, approximately 17:1, in the Health Physics Operations group.
Root Cause Root cause investigations revealed that Health Physics procedure RPP 02-215 is vague and open to individual interpretation in some areas of posting requirements.
The term " conspicuously marked" leaves the interpretation up to each individual.
Contributing Causes:
- 1. Due to Health Physics Technician staffing versus work load considerations, Health Physics supervision changed a past practice, and did not meet the Site ALARA Committee requirement, by not assigning a house Health Physics Technician to continuously cover the work.
- 2. Health Physics Supervision provided littic "in the field" guidance or monitoring of the work, 1 caving the contract workers to use their own judgment.
The administrativt work load and the number of workers th4t the Health Physics Supervisor Operations is directly responsible for, at least seventeen workers on a routine basis, did not allow for the time "in the field" needed to ensure work meets management expectations.
, Corrective Steps Taken and Results Achieved:
On August 14, 1997, a Health Physics Technician was dispatched to the area of concern.
He placed a posting containing all required information in direct line of site from the door coming from the 2047' elevation of the Auxiliary Building, and verified the remaining postings around the Spent Fuel Pool.
- On November 21, 1997, the Superintendent cf Racintion Protection issued a message to all Health Physics technicians and supervicors, on management expectations regarding the requirements of " conspicuously marked" costing.
Corrective Steps To Be Taken:
Health Physics Department will review the Hetlth Physics procedures for accuracy and usability. This review will be completed by March 31, 1998.
Health Physics management will evaluate:
- 1. The need for dedicated personnel to perform procedure reviews;
' Attachment to WO 97-0133
. Page,8 of 8
- 2. The use of contract personnel without dedicated in-house oversight; and,
- 3. Actions necessary to ensure proper in-house Health Physics staffing.
This evaluation will be completed by March 31, 1998.
Health Physics and Executive management will evaluate responsibilities of direct line Health Physics-supervisors.
This review will include supervisory time spent "in the field"; organizational structure; and worker-to-supervisor ratios.
This evaluation will be completed by March 31, 1998.
Date When Full Compliance Will Be Achieved Full compliance was re-established on August 14, 1997, when a Health Physics Technician, who was dispatched to the area of concern, placed a posting containing all required information in direct 1 of site with the door coming from the 2047' elevation of the Auxiliary Uniding.
This technician also verified the remaining postings around the Spent Fuul Pool.