ML20203F522
| ML20203F522 | |
| Person / Time | |
|---|---|
| Site: | Palisades  |
| Issue date: | 04/18/1986 |
| From: | Johnson B CONSUMERS ENERGY CO. (FORMERLY CONSUMERS POWER CO.) |
| To: | NRC OFFICE OF ADMINISTRATION (ADM) |
| Shared Package | |
| ML19298D916 | List: |
| References | |
| NUDOCS 8604250172 | |
| Download: ML20203F522 (2) | |
Text
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Consumers Power rommns MKJNGAN5 PROGRESS General Offices: 1945 West Patnall Road. Jackson MI 49201 e (517) 788 0550 i
April 18, 1986 US Nuclear Regulatory Commission Document Control Desk Washington, DC 20555 DOCKET 50-255 - LICENSE DPR PALISADES PLAST -
REPORT OF OVEREXPOSURE FOR MARCH 1984 DIVER INCIDENT Pursuant to 10CFR20.405(a)(1) 6 (2) and 10CFR20.405(d) the two attachments to this letter are being submitted as a compilation of information previously submitted either formally or informally pertaining to the unplanned exposure of a diver at the Palisades Plant in March of 1984. This event was documented by IE Inspection Report 50-255/84-C6 dated July 11, 1984. Our response, dated August 15, 1984 which address 10CFR20.405(a)(1) and 10CFR20.405(d) is contained in this submittal as Attachment II.
The information needed to address 10CFR20.405(a)(2) is given in Attachment I.
Since this information constitutes a personnel file, it is requested that Attachment I be withheld from the NRC Public Document Room per 10CFR2.790.
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^d Brian D Johnson Staff Licensing Engineer CC Administrator, Region III, USNRC NRC Resident Inspector - Palisades AttacFaents 8604250172 860418 PDR ADOCK 05000255 G
PDR OC0486-0078-NLO4
es ATTACIDENT II Consumers Power Company.
Palisades Plant Docket 50-255 i
i l
1 RESPONSE TO IE INSPECTION REPORT 84-06
. DATED AUGUST 15, 1984 April 18, 1986 l
s II I:
6 Pages I
IC0785-0078-NLO4 ii--
Camumers power Campny o.a.<w om: toas w.= e.ra.a a
- e. ac ui 4emos. isin tesosso August 15, 1984 James G Keppler, Administrator Region III US Nuclear Regulatory Commission 799 Roosevelt Road Glen Ellyn, IL 60137 M
DOCKET 50-255 - LICENSE DPR PALISADES PLANT - RESPONSE TO IE INSPECTION REPORT 84-06 o
IE Inspection Report 50-255/84-06 dated July 11, 1984 identified four items of noncompliance. These items were discussed with your staff in an enforcement P
conference held on April 27, 1984 A telephone conversation between PClovendale of your st.af f and TCBordine of Consumers Power Company on August 10, 1984 extended the response date for these items to August 17, 1984. The fet. lowing is our response to the items:
Noacompliance (50-255/84-06-05)
N 10 CFR 20.101(b) states in part that during any calendar quarter total occupa-tional dose to the whole body of an individual shall not exceed 3 rems. " Dose F
to the whole body" is deemed to include any dose to the whole body, gonads, active blood-forming organs, head and trunk, or lens of eye.
j l
M Contrary to the above, an individual who worked as a diver in the refueling l
cavity during the first calendar quarter in 1984 received a doss of about
)
4.5 rems to the right leg above the knee, a portion of the body covered by the j
whole body dose limit of 3 rema per quarter.
Corrective Action Taken and Results Achieved During a routine check of the diver's dosimetry between work periods a high exposure was determined. At that time a radiological Stop Work Order was issued by the Duty Health Physicist. An investigation team, designated by the Plant Manager, conducted a thorough review of the incident and its precursors.
In a formal written report, the investigation team concluded:
- 1. Management controls for radiological work. failed. Health Physica planning had been performed, particularly with respect to dosimetry; however, it was not comprehensive, and was not integrated into the maintenance planning, as would have been appropriate.
OC0884-0006-NLO2 ma.
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67G D %,IWM 1
JGKepplOr, Adminictrcter 2
Pclisad A Plant
- RESPONSE TO IEIR 84-06
. August.15, 1984
.2. A failure oc' cur' red at the technician level to properly communicate several pieces of critical survey information, both between shifts and to their supervision. These survey results, significantly at odds with the prejob survey, failed to trigger either a halt to the work or a review of the Radiation Work Permit controls as required by procedures.
- 3. Insufficient time was applied to analysing the riska associated with the unexpected repair work to the fuel transfer equipment. The presence of highly mobile, high specific activity crud from fuel handling was not reccgnized. Other high radiation area work (eg, entry under the reactor vessel for cleaning) going on during the same period diluted the ALARA planning resources. The need for Radiation Protection Management to carefully monitor and, if necessary, limit the quantity of high risk radiation work proceeding simultaneously is a principal lesson reinforc-ed by this incident.
1 1
The investigation report developed extensive remedial and permanent corrective r
actions. The diving work was permitted to proceed only after a detailed Radiological Work Plan was developed, which included partial decontamination C'
of the work area and coverage by a dedicated health physics technician team under an experienced senior technician and closely supervised by the Duty Health Physicist. The work was completed under this plan, with an additional c-dose commitment of less than 100 area.
As discussed in the NRC inspection report, a technical evaluation of the j
extensive dosimetry information available, including consideration of the age i
of the individual involved, led to a conservatively estimated whole body dose assignment to the diver of 1630 area. As a result of the NRC determination expressed in this item of noncompliance, a revised Termination Report has been forwarded to the individual. In that report, we have explained the circus-stances of the change and indicated what actions he should take to notify any Lr subsequent employers. We have expressed our willingness to meet with him and assist him, if needed.
pq Corrective Action to be Taken to Avoid Further Noncompliance As discussed at the enforcement conference held on April 27, 1984, actions taken to prevent recurrence of unwarranted exposures of this nature are as follows:
- 1. A formal Radiation Work Plan, incorporating the generic precautions for any radiological diving work, has been promulgated.
- 2. A policy has been established whereby work in high radiation areas 21R/hr requires the presence of an experienced Health Physics management person on site. Exceptions to this policy must be approved by the Radiation Protection Manager.
- 3. New, more reliable underwater survey equipment has been procured. In future diving work, a minimum of two underwater survey instruments will be used, one always in immediate proximity to the diver.
OC0884-0006-NLO2 I
JGKeppler, Adminictrcter 3
Palisades Plant RESPONSE TO IEIR 84-06 August.15, 1984
- 4. Detailed rev'iews of the incident were conducted by the Radiation Protec-tion Manager for all health physics technicians and, independently, with their supervisors, on all aspects of the investigation and the noncompli-ances identified in the NRC inspection report. Particular emphasis was given to procedural compliance and awareness to changing radiological conditions including initiating or altering actions based on the chang-ing conditions and resisting the momentum of any job if time is needed to properly resolve problems.
- 5. The lessons learned from this event have been promulgated to other plant departments and, as appropriate, throughout the company. Particularly, these lessons are being incorporated in both the ALARA and Chemistry /
Health Physics Technician training courses.
- 6. A formal Radiation Work Plan has been developed for decontamination of the fuel handling upender tilt pits.
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- 7. As part of the Refueling Outage Health Physics Report, a post-job review of all work on fuel handling equipment has been performed. Action items to incorporate ALARA precautions in future planning have been identi-fied.
c3 T'
Date When Full Compliance Will be Achieved Full compliance has been achieved. The above stated actions are complete.
Noncompliance (50-255/84-06-02)
Technical Specification 6.12 requires that any individual entering a high Ss radiation area be provided with a dose rate monitoring device, or be provided with a dose rate integrating device which alarus at a preset dose (surveyed L"
areas only), or be accompanied by an individual qualified in radiation protec-tion procedures who is equipped with a dose rate monitoring device, w provides positive control over activities, and who erforms per n surveys pq as specified by the radiation work permit.
Contrary to the above, on March 18, 1984, a diver made three entries into the refueling cavity tilt machine area, a high radiation area, without being provided with a dose rate monitoring device or a dose rate integrating device or without being accompanied by an individual qualified in radiation protec-tion who was equipped with a dose rate monitoring device and who provided the required controls and monitoring.
Corrective Actions Taken and Results Achieved G
In the investigation of this incident, it was determined that, although no dives occurred without a workable survey instrument in the water, the techni-cians providing coverage for the job did not employ the instruments in direct proximity to the diver as required to meet the procedural and Technical Specifications requirements. This deficiency was corrected in the detailed OC0884-0006-NLO2
JGKepplcr, Adminictrctst 4
Palisades Plant
- RESPONSE TO IEIR 84-06 August 15, 1984
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plan for tbs resumption of repair work. The work was completed in full compliance with survey requirements.
Corrective Actions Taken to Avoid Further Noncompliance In the review of this incident with the health physics staff, special emphasis was placed on the need for representative surveys under all circumstances where a high radiation area may exist. Techniques to deal with the additional complications posed by surveying underwater were discussed. lE Information Notice 82-31 was again reviewed and the requirement for use of a minimum of two underwater survey instruments has been implemented.
Date When Full Compliance Will be Achieved Full compliance has been achieved.
Noncompliance (50-255/84-06-04) n Technical Specification 6.11 states that procedures for personal radiation protection shall be prepared consistent with 10 CFR Part 20 and shall be r5 approved, maintained, and adhered to for all operations involving personal radiation exposure.
C'
- 1. Procedure No 7.02, "ALARA Program", requires that an ALARA review be conducted if, among other things, a potential exists for individual exposure to general area radiation levels greater than 1000 mress/ hour; an individual is expected to exceed 1500 mrems whole body dose for a given task in a calendar year; or loose surface contamination exceeds a
100,000 dpm/100cm,
as Contrary to the above, no ALARA review was conducted of the refueling cavity IF tilt machine repair job aven though surveys and dose estimates indicated that dose rates might exceed 1000 ares / hour, that the diver's whole body dose was expected to exceed 1500 mrema for the job, and that contamination levels (dry) 8 pq exceeded 100,000 dp /100 cm (SIC).
- 2. Procedure No 7.03, " Radiation Work Permit", requires that a job be secured (stopped) if unplanned changes in working conditions occur which might invalidate the basis for an applicable radiation work permit.
Contrary to the above, the refueling cavity tilt machine repair job was not stopped even though radiation levels in the work area as high as seven times greater than those identified on the radiation work permit were identified.
- 3. Procedure No EP 2.14 " Radiological Survey Requirements", states that radiation work permits shall include applicable requirements for contin-uous, intermittent, and/or pre-job and post-job surveys.
Contrary to the above, the radiation work permit written for the refueling cavity tilt machine repair job did not contain any survey requirements.
OC0884-0006-NLO2
JGKeppl r, Administrator Palisades Plant RESPONSE TO IEIR 84-06 August. 15, 1984 Surveys conducted during the diving operation were not sufficient to identify the existing radiological conditions.
Corrective Action Taken and Results Achieved.
A detailed ALARA review was performed prior to lif ting the "Stop Work" order on repair of the fuel handling equipment. All requirements of Administrative Procedures 7.02, 7.03 and Health Physics Procedure HP 2.14 were complied with.
Corrective Action to be Taken to Avoid Future Noncompliance in the reviews of the incident, health physics personnel were instructed in the appropriate procedural requirements. The Training Department has been provided with full details of the event to be used for future Technician and ALARA training with emphasis on underwater procedures and the importance of ALARA reviews.
Bs Date When Full Compliance Will be Achieved Full Compliance has been achieved.
c7 Noncompliance (50-255/84-06-01) 7' 10 CFR 20.401 requires that records be maintained of surveys made by the licensee to determine compliance with NRC regulations.
Contrary to the above, no records were maintained of radiation surveys conduc-ted on March 18, 1984, to assess the underwater radiation hazards present in the refueling cavity tilt machine area.
Bs Corrective Action Taken and Results Achieved tr Individuals who failed to properly document surveys were counselled on the importance of this basic technician responsibility. The cause and effect p;
relationship between undocumented surveys and the eventual diver overexposure was stressed to these personnel.
Corrective Action to be Taken to Avoid Future Noncompliance The significance of this noncompliance was addressed to health physics personnel in the reviews of the entire incident. The Training Department has been provided similar information to be included in future Technician and ALARA training courses.
OC0884-0006-NLO2
.s JGKappl r, Adminictrcesr 6
Palisades Plant
_s RESPONSE TO IEIR 84-06 August. 15, 1984 Date When Ptall Com'eliance Will be Achieved Full compliance has been achieved.
David J VandeWalle (Signed)
David J VandeWalle Director, Nuclear Licensing CC Director, Office of Nuclear Reactor Regulation Director, Office of Inspection and Enforcement NRC Resident Inspector - Palisades ec S
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N Lr 9
M OC0884-0006-NLO2
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