ML20206N978

Insp Rept 50-362/86-37 on 861215,870112-16 & 0316-20. Violations Noted:Failure to Control Licensed Matl to Maintain Exposure within Regulatory Limits,Perform Required Surveys & Provide Immediate Notification of Events to NRC

ML20206N978
Person / Time
Site:	San Onofre
Issue date:	04/10/1987
From:	North H, Russell J, Wenslawski F, Yuhas G NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V)
To:
Shared Package
ML20206N955	List: ML20206N951 ML20206N978
References
50-362-86-37, NUDOCS 8704210068
Download: ML20206N978 (24)

See also: IR 05000362/1986037

Text

. . . . --- . _ .

=~

.

,

U. S. NUCLEAR REGULATORY COMMISSION

,

REGION V

I

Report No. 50-362/86-37

Docket No. 50-362"

License No. NPF-15

Licensee: Southern California Edison Company

2244 Walnut Grove Avenue

'Rosemead, California 91770 i

4

Facility Name: San Onofre Nuclear Generating Station - Unit 3

Inspection At: San Onofre Nuclear Generating Station

'

Inspection Conducted: December 15, 1986, January 12-16, 1987, and

March 16-2 , 1987

Inspectors: /u v. 9-f7

'

J. gRu sell Date Signed

j Radiation Specialist, C.H.P.

0 0th - An 4hoh7

H. S. NottA )~ C.H.P.

Senior RaMtion Spe(Malist,

Date Signed '

l

( Y

G. P. Nhasj Chief

1'll011W

Date Signed

'

Faci itie M adiological Protection Section

Approved by: .I #7

F. A. Wehslawski, Chief Datre S'igned ,

j Emergency Preparedness and Radiological I

i Protection Branch

Summary:

s

'

Inspection on December 15, 1986, January 12-16, 1987, and March 16-20, 1987

(Report No. 50-362/86-37)

Areas Inspected: This was a special inspection in response to the licensee's

,

December 12, 1986, report of a potential exposure to the hand of a worker in

excess of the regulatory limit. The inspection included an onsite visit by

the Chief, Facilities Radiological Protection Section; subsequent site

inspection effort by regionally based Radiation Specialists, NRC Headquarters

i Staff and the Resident Inspection Staff; extensive in office review; and

independent technical evaluations by NRC consultants. The purpose of the

inspections was (1) to determine if the worker received the exposure and (2)

to establish the adequacy of the radiation protection controls imposed by the

l

licensee to minimize the potential for unplanned exposures to workers from

8704210068 870413

i PDR ADOCK 05000362 <

'

O PDR

)

. . . - . . . -.. . . - . . - .- - .- -- . . . . . .

. . . ,

S

-

.

1-

!

-2-

i.> .

-

! small particulate sources of radioactive material. Inspection procedures

'

addressed were 83729, 90712, 92700 and 93702.

! Results: Of the areas inspected, apparent violations involving failure to

i control licensed material to maintain exposure within regulatory limits;

i failure to perform required surveys; failure to provide immediate~ notification

of events-to the NRC; and failure to control licensed material to prevent

{ release to unrestricted areas were identified.

t

1

I +

!

'

I

i ,

i

4

?!

I

@

!

.

i

1

'

1

.

l -

..

l

4

!

i 4

i r .

i

( *

f

'

i

!

k

i

}

4

,

.

'

DETAILS

I. Persons Contacted

Licensee Personnel

+*H. Ray, Vice President - Site Manager

+*H. Morgan, Station Manager

r + M. Wharton, Deputy Station Manager

+*P. Knapp, Health Physics (HP) Manager

+*R. Warnock, HP Engineering Supervisor

+*W. Zint1, Compliance Manager

• C. Couser, Compliance Engineer

+*D. Schone, Site Quality Assurance (QA) Manager

+*E. Donnelly, HP Engineer

Maintenance Worker A

,

R. Dickey, Dosimetry Supervisor

i + J. Reilly, Station Technical Manager

,

+ A. Brough, Station Technical Engineer

l + S. Stilwagen, Refueling Supervisor

Licensee Contractors

HP Technician A

+ P. Plato, Professor of Radiological Health, University of Michigan

NRC Contractor

~

F. Attix, Consulting Physicist, Department of Medical Physics, University

of Wisconsin

R. Brown, M.D., School of Medicine, University of California

M. Moeller, Senior Research Scientist, Health Physics Department,

Battelle Pacific Northwest Laboratories

NRC Representatives

+ R. Huey, Senior Resident Inspector

+ J. Tatum, Resident Inspector

,

P. Stewart, Resident Inspector

+ R. Paulus, Health Physicist, Operating Reactor Programs Branch, IE

A. Johnson, Enforcement Officer

S. Block, Region V, Health Physicist, C.H.P.

• Denotes individuals present at the exit interview on January 16, 1987.

+ Denotes individuals present at the exit interview on March 20, 1987. .

In addition to the individuals identified above, the inspectors met and

held discussions with other members of the licensee's and contractor's

staff.

I

_ _ _ _ _ _ _ _ _ _ _

.

II. Background

On December 12, 1986, at 11:30 a.m. (PST), Southern California Edison

Company (SCE) made a report pursuant to 10 CFR 50.72(b) of a potential

dose to a worker's right hand of 511,990 mrem. The dose to the worker's

left hand and whole body, as read from his other TLD badges, was 160 mrem

and 114 mrem, respectively. In response to this notification, the Region

V Chief, Facilities Radiological Protection Section conducted an initial,

onsite inspection on December 15, 1986, to determine if the licensee was

dedicating sufficient resources to evaluate the potential exposure and to

verify that the licensee was in the process of implementing additional

radiation protection measures to control potential exposures from

radiation sources.

In anticipation of the licensee's submittal of a Licensee Event Report

(LER), two regionally based radiation specialists reported to the site on

January 12, 1987, to perform an independent evaluation of the event. LER

86-015 was issued on January 12, 1987, but indicated that the licensee

had not completed their investigation and that a revision to the LER

would follow.

The licensee issued LER 86-015, Revision 1, on February 22, 1987,

reporting their conclusion that the overexposure did not occur. The

basis for the licensee's conclusion was to be contained in a report to

follow.

On March 3,1987, the licensee issued a final report, Evaluation of the

reported high exposure to extremity TLD #80365 in October, 1986,

describing the investigation and providing the bases for their conclusion

that the overexposure did not occur. After review of the licensee's

final report, the Region V Facilities Radiological Protection Section

Chief, an headquarters Inspection and Enforcement Health Physicist, the

Region V Enforcement Officer and a regionally based Radiation Specialist

reported to the site on March 16, 1987, to complete independent onsite

investigation of the event. During this same period, the Region V l

Emergency Preparedness and Radiological Protection Branch Chief and a NRC l

consulting physicist and dosimetry expert visited the facilities of the

licensee's dosimetry vendor to review the vendor's processing of the TLD

badge in question.

As a result of NRC comments made during the exit interview on March 20,

1987, the licensee submitted LER 87-003 on March 24, 1987, pursuant to 10

CFR 20.405(a)(1)(v) in which the licensee provided information regarding

three occurrences in which small particles of licensed material had

apparently been released from the site.

III. Licensee Evaluations

1. Initial Investigation of 512 Rem Exposure

In LER 86-015, the licensee described the initial information

available to them as follows:

__

.

.

3

"On December 12, 1986, SCE determined that sufficient *

preliminary information existed to believe that an extremity

exposure to one individual's right hand in excess of the

regulatory limit of 18 3/4 Rem / Quarter may have occurred in

October 1986 during maintenance work at Unit 3. Subsequent

investigations are not complete and thus have not established

whether the extremity exposure actually occurred. The

individual was restricted from further exposure for the

remainder of the Fall 1986 quarter. He resumed his normal

activities on January 1,1987.

"During October 1986, an SCE Maintenance individual wore two

ring TLDs, one on the ring finger of each hand, provided

by...(the)... (TLD Service), on five occasions during

maintenance work on a Liquid Waste Management System (LWMS)

Crud Tank Pump...and the Reactor Coolant System (RCS) reactor

coolant pump seals... removal and reinsta11ation. The dates of

the maintenance work were October 6, 8, 9, 20 and 21, 1986. On

October 30, the rings were removed from use and routinely

forwarded to the TLD Service for analysis.

"The TLD Service reported to SCE via electronic data

transmission to the SCE computer system, all October TLD

results on November 13, 1986. Due to an error in the SCE

computer data reformatting program, a reading above 9.999 Rem

was truncated, dropping any digits above the first place to the

left of the decimal point. As a consequence, the computer

program feature to automatically identify excessive exposure

data failed and SCE remained unaware of a high reading for one

of the Maintenance individual's ring TLDs.

"On or about November 17, 1986, the TLD Service, as is

customary, provided the backup printed listing of the

electronic data transmission to SCE. On December 11, 1986, SCE

dosimetry personnel checked the October dosimetry records and

noted a reading above the 18 3/4 Rem / Quarter regulatory limit

for extremities. After confirming the data with appropriate

vendor personnel on December 12, 1986, NRC notification was

made and a comprehensive investigation was initiated."

The licensee summarized the status of their investigation by

stating:

"0ngoing investigations thus far have been unable to establish

whether the extremity exposure actually occurred. However, if

it did actually occur, the only plausible mechanism would be

from a small fission fuel fragment (FFF). At present, it

appears equally likely that the TLD reading was anomalous or

was caused by tampering. The ongoing investigations should be

completed in February "

!

In regard to the problem with fuel fragments, the licensee stated:

,

- -- . . - . - - -

-

l .

4

l

1

l

"During the first fuel cycle of Unit 3, Fuel degradation. r

occurred which resulted in small (size from approximately 0.18

cm down to less than 1 micron) Uranium Dioxide FFFs being

liberated to the RCS and spent fuel pool. As a result of

[

liquid radwaste processing, FFFs could also be transported to

'

the LWMS. The activity of FFFs ranges from E-3 to E+3

microcuries. Considering the makeup of the radioactive

parent / daughter nuclides from an FFF,'these small fragments are

characterized as a significant Beta (1.5 Mev average energy) ,

source and a relatively insignificant gamma component...

.

"Due to the presence of FFFs at Unit 3, SCE had previously-

instituted a program to minimize personnel contamination and

exposure, and spread of the FFFs at the time that FFFs were

identified during the initial refueling of Unit 3. This ,

program was further enhanced in November 1986 to upgrade

training and indoctrination of supervision and personnel

regarding the hazards, special health physics coverage of

ongoing work in areas and systems known, or suspected of being

contaminated with FFFs, and frequent beta monitoring. For the

January 1987 Unit 3 refueling outage, SCE initiated enhanced

monitoring which included a "stop work" requirement if the

presence of an FFF is detected in an area which-is not already

under special FFF controls."

<

The licensee conducted a medical examination on December 18, 1986,

of the individual in question and reported that they did not expect

or observe any health effects associated with the extremity

exposure. In addition, the licensee reported that the individual

stated that he had observed no erythema or epilation.

.

"

The licensee reported that radiation surveys performed prior to and

immediately after the individual's work activities did not indicate

radiation or contamination levels which would have resulted in the

exposure. Personnel frisking and personnel monitoring booths had ,

not detected any contamination on the extremities of the individual '

involved. The licensee reported that, although their investigation

was not complete, they were investigating the TLD response,

potential tampering and deliberate exposure of the individual ring

and that a final report would be submitted. *

During the January 12-16, 1987, visit, the inspectors confirmed

that, due to errors in the licensee's computer programming, the

initial TLD reading of 511,990 mrem was truncated to 1,990 mrem. As

this figure was below the licensee's administrative limit, it was

not flagged by the programming. The inspectors also verified that a

hard copy report of the exposure had been received on or about

November 17, 1986, but had not been reviewed by the licensee's

staff. The hard-copy report was not reviewed until December 11,

1986, when a dosimetry clerk, performing the routine end-of-month

comparison of multiple dosimeters, began investigating the ,

difference between the whole body TLD reading, 114 mrem, and the

Pocket Ionization Chamber (PIC) reading, 162 mrem, of the individual

in question. The hard-copy report indicated a dose of 511,990 mrem

to the right hand. The staff member brought the report to the

L--

-

.

5

attention of the Dosimetry Supervisor who informed the HP

Engineering Supervisor and he informed the HP Manager at

approximately 4:00 p.m., December 11, 1986. The HP Engineering

Supervisor contacted the dosimetry vendor at approximately 5:35 p.m.

and again at approximately 6:25 p.m. and confirmed that the report

was valid and had been reviewed by the vendor Health Physicist. The

HP Manager notified the Station Manager shortly thereafter. After

contacting the vendor Health Physicist the next morning to further

verify that the reading was not incorrect, the licensee notified the

NRC at 11:30 a.m., December 12, 1986.

Based on a review of records, the TLD was read on November 10, 1986.

Although the TLD vendor's procedures would normally require

telephone notification of the exposure to the licensee, no

notification was made. The licensee representative informed the

inspectors that the contract with the TLD Service did not

specifically require a telephone notification. The inspectors were

informed by the licensee that the computer software, implemented in

February 1984 to expedite the handling of dosimetry data, had not

been validated, verified or documented. Specifically, these

programs are:

i

i GENCOM - Receives electronic data transmission from the vendor

LNDXMIT - Reformats data and creates file in mainframe

SRPRCS - Takes information from LNDXMIT created file and

updates dosimetry file

SCERJE - Updates file on mainframe from lab

TLDOSE - Extracts data from SCERJE fcr reports

With respect to reporting overexposures, the inspectors brought to

the licensee's attention that 10 CFR 20.403(a), Immediate

notification, states: "Each licensee shall immediately report any

event involving byproduct, source, or special nuclear material

possessed by the licensee that may have caused or threatens to

cause: (1)... exposure of the feet, ankles, hands or forearms of any

individual to 375 rem or more of radiation." Since the licensee had

sufficient information available on November 17, 1986, to enable him

to recognize and report the potential overexposure yet failed to do

so, this is considered a violation of the reporting requirement.

Failure to immediately notify the NRC of an event that may have

caused or threatens to cause an exposure to the hand of an

individual to 375 rem or more is an apparent violation of 10 CFR l

20.403(a). (86-37-01)

l

The dosimetry supervisor informed the inspectors that all written

reports from the TLD vendor since implerentation of the defective

programs had been reviewed and no other extraordinary exposures were

identified. The licensee staff informed the inspectors that they i

had instituted action to validate, verify and document the software.

I

4

1

-

.

6

2. Licensee Conclusion Relative to the 512 Rem Exposure

With respect to the apparent overexposure of a maintenance worker's

right hand, the licensee's final report, Evaluation of the reported

high exposure to extremity TLD #80365 in October, 1986, provided the

bases for their conclusion-that the exposure report was invalid.

These were:

A. "The residual reading (on the TLD) was unreasonable and

unreproducible in the dose range reported;

B. "No sources capable of delivering such a dose were available

within a vanishingly small probability;

C. " Extensive radiation and contamination surveys failed to detect

any such sources; and

D. "No conclusive medical evidence of such an exposure was found."

The licensee's report documented their investigation and conclusion

that it was unreasonable to attribute the TLD reading to tampering

or inadvertent exposure, citing the trackable control history of the

TLD rings and procedural controls instituted by the licensee and

their vendor.

The licensee's report describes visits by their consultant Health

Physicist to the vendor facility and a number of experiments which

were performed at the licensee's request. The consultant's report

to the licensee documents his investigation into. vendor procedures

and the handling of the TLD in question. The consultant's report

documents that, when the TLD in question was initially read on a

reader designated "AA" by the vendor, it provided a high initial

light output, 5.12E6 nanocoulombs; and that, in accordance with

vendor procedures, the TLD chip was irradiated to 350 mrem with a

Sr/Y-90 source and reread on a reader designated "BB" by the vendor

and provided a higher than expected second output, 5.63E5

nanocoulombs. The consultait documented that the vendor performs

the irradiation and second reading to determine a unique calibration

factor for each chip, that the readers used were recently put into

use and that the chips are heated by a laser rather than hot gas.

The licensee's report centers around the premise that if the

exposure is real, the reading on the badge including what the

licensee terms the " residual" should be reproducible. The licensee

documents numerous experiments involving irradiation of TLD chips

with different types of radiation, with dif ferent levels of

exposure, and at different exposure rates. The licensee documented

experiments involving reading TLDs with different readers, both

laser heated and gas heated. The licensee documented experiments

involving contaminating TLD chips with physical and chemical agents

and chip overheating. The licensee documented experiments that

could involve variations in reader calibration over a two-month

period,

m

_ _ .__ ..

-

.

7

The licensee's experiments were unable to produce an initial light

output equivalent to a 500 rad dose by any means other than

irradiation of a TLD. Of the experiments conducted, the licensee

reported that only very high exposures, those greater than 65,000

rem, duplicated the large " residual" seen when the badge in question

was read. The licensee conducted no experiments to investigate the

effect of inadequate heating of the TLD chip as a method of

producing a similarly high " residual" reading. The licensee's

inability to reproduce the exposure by the undertaken experiments

precipitated their conclusion that the TLD reading was invalid.

4 In addition, the licensee concluded that no sources of radiation ,

capable of delivering such a dose were available within a

vanishingly small probability by analyzing the distribution of

irradiated fuel fragments and Co-60 particles found outside the fuel

handling building, the majority of which had been found after

i January 2, 1987. The analysis failed to consider numerous higher

activity particles found within the fuel handling building and other

particles found before January 2, 1987.

,

The licensee's report stated that extensive radiation and

contamination surveys did not detect any sources capable of

i delivering such a large dose. No records were made of any radiation

< or contamination surveys performed during actual work activities

while the ring was being worn. The licensee documented two air

samples taken during the work activities and also documented the

radiation and contamination levels as recalled by the involved

workers and technicians two months subsequent to the time the ring

was worn.

The licensee's report documents that no conclusive medical evidence

of such an exposure could be found based on examination of the

'

worker's hands and blood samples two months after the potential

occurrence.

j 3. Investigation of Released Particles

Following the January 12-16, 1987, inspection, two events involving

i control of fuel fragments were brought to the NRC's attention by the

licensee by telephone. LER 87-003, submitted on March 24, 1987,

-

describes these occurrences as well as an additional occurrence not

! previously brought to the NRC's attention. The two events,

previously brought to NRC's attention, were reviewed during the

March 16-20, 1987, inspection. In addition, the Senior Resident

Inspector documented his observations regarding implementation of

the fuel fragment control program in Inspection Report No.

50-362/86-38.

The licensee reported that the first event involved a contract

worker on February 2, 1987. The worker's protective clothing became

contaminated and, after removing them and while wearing only modesty

! garments, the worker was surveyed by a whole body contamination

monitor, a PBM-200. The worker repeatedly alarmed the monitor but

hand frisking of only the suspect area with a E-140 detected no

_ _ .

-

j .

8

'

?

i

i

contamination. A whole body frisk was not performed. The worker

was eventually released from the restricted area and upon his retu n

on February 3, 1987, he again alarmed the PBM-200. On this occasian .

a HP technician conducted a full body frisk of the individual and

located a particle on the sleeve of his jacket. The particle was

four,d to be a 0.08 microcurie irradiated fuel fragment which

produced a calculated contact dose rate of approximately 400

mrem /hr. The licensee surveyed the worker's residence and

automobile and found no further contamination. The licensee

concluded that they had recovered all the radioactive material t1at

could have left the site on the worker's body. The licensee

estimated that the dose to the worker was 1.77 rem to the skin cf

the whole body and 1.20 rem to the extremity and that the worket's

family received no appreciable exposure. This was based on the.r

conclusion that the particle was transferred from the individuas

upper arm, where it was initially located when the PBM-200 alarned,

to the worker's jacket during his drive home, that the particle was

removed from contact with the worker's body when he removed his

jacket at his residence, that the other members of the worker's

family did not contact the jacket and that the particle was again

put in contact with the workers lower arm when he donned his jteket

the next day.

The licensee reported that the second event involved a site HP

technician on February 19, 1987. The HP technician found that his

shoe was contaminated on the outside as he was entering the fa:ility

restricted area at the beginning of his shift. The shoe was

discarded, so the activity of the particle and its composition could

not be determined. The licensee determined that a radioactive

particle may have been embedded in the technician's shoe and might

have been previously removed from the site. The licensee is

continuing the investigation.

The licensee reported that the third event involved a site HP

technician on February 21, 1987. The technician discovered what was

later determined to be 0.2 microcurie irradiated fuel fragment in

the carpet of his residence during a self-initiated survey of his

home with an E-140. The technician stated that he had been

concerned that irradiated fuel fragments might have gotten offsite

as these fragments had been found outside restricted areas and that

the sensitive instrumentation used to detect these particles, the

PBM-200 personnel monitoring booths, had only recently been put into

use. The contact dose rate produced by the particle at the time it

was found was calculated to be approximately 1200 mrem /hr. The

licensee determined by isotopic distribution that the particle was

approximately one year old. The licensee has not yet assigned a

dose to the technician or estimated the dose to which the

technician's family was exposed as a result of this occurrence.

10 CFR 20.301 and 10 CFR 30.41 require that no licensee shall

dispose or transfer licensed material, except as authorized. In

addition, 10 CFR 20.105(b) requires that, except as authorized by

the NRC, no licensee shall possess, use or transfer licensed

material in such a manner as to create, in any unrestricted area,

l

l

,

_ _.

-

.

9

radiation levels which, if an individual were continuously present,

could result in his receiving a dose in excess of two millirem in

any one hour or 100 millirem in any seven consecutive days.

..

The inspectors noted that-the 0.2 pCi source could result in a dose

of 1200 mrem /hr to the skin of an individual or 27 mrem /hr to the

limiting organ if it were continuously present on the individual.

For example, if the speck were to become embedded in an individual's

clothing (as previously observed in SCE modesty garments) a member

of the public could receive a localized dose well in excess of

acceptable limits within a few hours.

The release of licensed material from the licensee's restricted area

to offsite areas is an apparent violation of 10 CFR 20.105(b),

20.301 and 30.41. (86-37-02) ,

i 10 CFR 20 states, under Precautionary Procedures in 20.201, Surveys,

that:

"As used in the regulations in this part, " survey" means an

evaluation of the radiation hazards incident to the production,

. use, release, disposal, or presence of radioactive materials or

other sources of radiation under a specific set of conditions. >

When appropriate, such evaluation includes a physical survey of

the location of materials and equipment, and measurements of

levels of radiation or concentrations of radioactive material' '

present.

"(b) Each licensee shall make or cause to be made such surveys

as (1) may be necessary for the licensee to comply with the

regulations in this part, and (2) are reasonable under the

circumstances to evaluate the extent of radiation hazards that

may be present."

During the inspection of March 16-20, 1987, the inspectors reviewed

the licensee's investigation of the February 2, 1987, and February

21, 1987, events. This review included discussions with the

individuals involved.

The licensee's staff determined that, in regard to the February 2

event, the individual had been working immediately adjacent to a

fuel fragment control area established in accordance with licensee

health physics procedure 50123-VII-7.12. The individual's

protective clothin0 became physically dirty and the individual

-

suspected he had become contaminated. The worker went to the

control point and requested the assistance of the llP technician.

The licensee representative stated that the HP technician determined

that the protective clothing was contaminated without determining

the extent, level or type of contamination. The technician surveyed '

.

i the individual and observed that the instrument was pegged. The

! individual was directed to remove the contaminated clothing without ,

special precautions. Specifically, in order to assess the dose to j

,

the worker and to minimize the potential for personnel contamination ,

during removal of the protective clothing and to prevent j

i

I

- - _ - - - _ - . _ . _ _ _ _ . . _ _ _ _ - - _ - - _ _ _ _ . - - . _ _ - _ - _ . _ _ - - - _ . _. - . - _ - _ . . _

,

'

'

10

distribution into the laundry pool, a survey to identify the extent,

location and type of contamination would have been appropriate.

Failure to make such surveys as are reasonable to evaluate the

extent of radiation hazard that may be present is an apparent

violation of 10 CFR 20.201(b)(2). (86-37-03)

After the individual removed his protective clothing, he performed

whole body monitoring in the PBM-200 beta booth and repeatedly

alarmed the monitor. The HP technicians responding to the alarms,

performed frisking type measurements of the individual but failed to

identify the radioactive material present. The HP technician

allowed the individual to leave the site in spite of the fact that

the worker continued to alarm the PBM-200. Failure to make such

surveys as are reasonable to evaluate the extent of radiation hazard

that may be present is an apparent violation of 10 CFR 20.201(b)(2).

(86-37-04)

In response to this event, the licensee terminated the HP

technician's employment, discussed the event with the staff and

instituted a policy that requires management approval for release of

any individual that continues to alarm a PBM-200 monitor.

The licensee evaluated the dose to the skin of the whole body of the

individual to be 1.77 rem and to the skin of the extremity of-the

individual to be 1.20 rem by postulating that the only contamination

present on the individual during the event was the particle found

the next day on the individual's jacket and that that particle had

been removed from the workers upper arm and attached to the cuff of

his jacket when the jacket was removed af ter the individual arrived

at his residence.

The inspectors, employing a conservative scenario that the particle

remained on the worker's skin until it was located on February 3,

1987, calculated that a dose to the skin of the whole body of the

individual on the order of 7 rem could have occurred. This dose

together with the individual's cumulative whole body exposure for

the first quarter of 1987, would not have been in excess of the 7.5

rem limit.

IV. NRC Evaluation of 512 Rem Exposure

(Note: The following paragraph designations A., B., C., and D. are

intended to coincide with the paragraph designations 2.A., B., C., and

D. on page 6 of this report.)

A. Dosimetric Indications

The Emergency Preparedness and Radiological Protection Branch Chief

and a Conruiting Physicist, export in the field of thermoluminescent

dosimetry, visited the vendor's facility to review the processing of

the TLD badge. The team reviewad the vendor's TLD handling

procedures from the time the TL0s are obtained from the supplier

J

until the time they are discarded, specific information relative to ,

'

the TLD in question, and the hardware used by the vendor.

i

_. . _ _ _ _ _.. _, . .. _. .

<

l

'

-

11

'The team found that the TLD chip in question was composed of lithium

i fluoride (LiF), commonly termed TLD-100, obtained from the vendor's

supplier. They found that after receipt from the supplier the

i

chipsareannealedandresponsecheckedbyexposingthechIpstoa

l known dose of radiation. The chips must respond within a certain

i range or they are discarded. The chips are then cleaned and sealed

l in plastic rings under a welded polyethylene cover. The rings are

! individually labelled and sent to the users with appropriate

controls. When the rings are returned they are surveyed for

contamination and then processed. The processing involves removing

the label, noting any damage to the ring, cutting the ring in half

to release the chip, loading the chip into a carousel with other

returned chips and controls, noting any damage to the chip, reading

the chip on the vendor's laser heating system, reirradiating each

chip to 350 mrem from Sr/Y-90, rereading the chip to determine a

unique calibration factor, annealing and cleaning the chips and

reloading them into rings. The vendor's procedures require that the

chip be read several times if the chip indicates a high dose and

that the chip then be discarded. The vendor's procedures also j

require that the vendor contact the user to report a high dose. The

team found that the vendor had not performed any rereadings of the

512 rem chip after the second read and that the vendor had not

contacted the licensee by telephone when the exposure was

discovered.

The use of lithium fluoride, TLD systems is a standard dosimetric

technique widely used throughout the industry. (See: Personnel

Thermoluminescence Dosimetry Systems - Performance, ANSI N13.15

1985). Lif systems respond primarily to ionizing radiation but can

provide a false indication if the chips are contaminated with a

substance which could burn or luminesce or if the chip is heated to

too high a temperature and it incandesces.

<

The team observed, relative to the possibility of incandescence

causing the high initial light output, that none of the other 45

user chips in the carousel during the first reading of the chip in

question produced a high light output and that the chip in question

produced a high output during the second read on a different reader.

The NRC consultant dosimetry expert observed that it was not

reasonable to attribute he large light output of the TLD to

overheating as this woub have had to occur only for the chip in

question and sequentially on two different machines.

The team observed the vendor's records of the chip in question,

relative to the possibility of contamination having caused the high

initial light output, and noted there was no record of any

'

contaminant being observed on the badge by the technician, that no

l foreign or charred material was observed in the carousel af ter the

l read, and that the laser heating is done in a nitrogen atmosphere

which would not be conducive to burning. The team also noted that

i the licensee performed experiments in which they contaminated TLD

I chips with various chemicals and agents and that these failed to

produce any responso greater than that equivalent to a dose of 50

mrem. The team also noted that, after a search of available

___________________________ _ ___

_

-

,

12 [

'l

literature, such false-light outputs had been observed but that

their magnitude was a factor of 100 less than the light output noted

in this event. (See: Hoots, S. S. and Landrum, V., Glow Curve

,

Analysis for Verification of Dose in LiF Chips, Health Physics 43, ,

'

905-912).

The team investigated the question presented by the licensee of the

second large light output, or " residual," observed during the

'

l calibration cycle of the chip in question. The NRC consultant noted

that there are varying opinions as to what the second light output

might and might not indicate and the magnitude of which might be

expected in certain situations. The vendor provided data to the

l team from a two chip badge recently processed by the vendor which

provided an initial reading of about 10,000 rad, a second reading of

60% of the first reading, a third reading of 10% of the first

reading and fourth through seventh readings of from 1% to 5% of the

first reading. The vendor also performed an experiment at the

l request of the team in which they varied the heating time with the

laser, thereby inadequately heating the chip. The vendor informed

the team that the heating time of the chip in question was 1 second

and that the experiments demonstrated that a reduction of the. -

heating time to 0.95 second resulted in light output, during the

second reading, of from 10% to 30% of the initial reading when the

l

chips had been exposed to about 500 rem.

l

This finding cicarly indicates that the " residual" effect was

reproducible and process parameters seem to indicate it was the most

likely source of the observed response of the SCE chip in question.

The vendor representative, after having reviewed their records and

after having performed numerous experiments stated:

! "I believe in light of these tests, we will continue our

l position, which is that we have not seen any data that would

cause us to qualify our original dose reported to Southern

California Edison."

The N9C's consultant and dosimetry expert stated:

"It is not only possible, but seems probable that TLD #80365

l

received a dose of ionizing radiation approximating that which

'

was reported."

In view of the findings presented above, it appears that the

licensee's conclusion that: "The residual reading was unreasonable

and unreproducible in the dose rango reported" is invalid.

8. Sources of Exposure

During the December 15, 1986, initial NRC inspection, the Section

Chief examined the licensee's investigation plan; contacted the

! involved HP Engineering and Plant Maintenance personnel; and

reviewed available records. The Section Chief determined that the

potential exposure could not easily be attributed to a particular

- . . - -

! .

-

-

.

13

P

l job or event. However, the most likely source of exposure that

could have resulted in a dose of this magnitude would have involved

'

.

direct contact of the worker's hand with a small particle of

irradiated fuel. Particles of this type were known to exist at Unit

l 3 following operation during cycle one with 105 defective fuel pins. ,

The Section Chief suggested to the licensee that their evaluation  !

carefully consider those systems which could contain fuel fragments

and involved maintenance performed by the worker. ,

l On March 18, 1987, the licensee's staff informed the inspectors that

t the site Health Physics organization had not been involved in the

planning phase of the fuel reconstitution effort following cycle 1

and that the Health Physics input was provided as a supplement to

the reconstitution plan. -The reconstitution / refueling supervisor

stated that highly radioactive particles were found early during the

reconstitution effort, in late 1985, and that this problem was

greatly exacerbated w'un, during reconstitution of the final fuel

bundle, a fuel pin was pulled apart. The supervisor recalled that

this necessitated greatly increased radiological control

requirements, isolation of the Fuel Handling Building from normal

access and the training of a special team of HP technicians in order

to locate these fuel fragments and decontaminate the building,

further details are contained in Inspection Report No. 50-362/86-02.

The Refueling Supervisor further informed the inspectors that all

the damaged fuel pins were grouped into one bundle and stored in the ,

Spent Fuel Pool without further containment.

'

The Refueling Supervisor informed the inspectors that the Fuel Pool

Cleanup System, which draws suction from below the racks in which t

the reconstitution was performed, was run both during and after

reconstitution. Based on a review of the FSAR and plant system

diagrams, the inspectors noted that the Fuel Pool Cleanup System ,

contains a backflushable filter, designed to remove particles

greater than 5 micrometers in size, and that these filters are

routinely backflushed into the Crud Tank systen. The inspectors

also noted that the Crud Tank liquid is circulated through shielded

disposable filters which, as indicated by a review of licensee

survey records, produced external gamma dose rates as measured with

a teletector of up to 120 R/hr. The inspectors also noted that  ;

similar backflushable filters of other primary systems are routinely

backflushed into the Crud Tank. The inspectors also reviewed the

design of the Reactor Coolant Pump Seals and Heat Exchangers and

noted that these provide areas which could trap circulating  ;

particles. A review of licensee surveys revnaled that the seal ,

areas have elevated dose rates due to accumulation of particulate ,

material on the seals, t

The inspectors reviewed a memorandum issued by the HP Manager on

November 15, 1985, requesting the assistance of the Station I

Technical organization to identify probable pathways for system  !

and  !

contamination, actionsproduct

Indications of fission neededcontamination

to ameliorate future problems,id

in various liqu  :

samples. The inspectors noted the response from a licensee Senior i

i

I

'

14

Engineer on February 4, 1986, which identified numerous systems

potentially contaminated with fuel fragments, specifically:

" Spent Fuel Pool Cleanup System

" Spent Fuel Pool Cooling System

" Fuel Handling Building Sumps and Drains and Contaminant

Sump

' Reactor Coolant Radwaste System

" Reactor Coolant Chemical Volume and Control System

" Containment Spray

" Nuclear Plant Sampling System"

The inspectors also noted a memorandum from the Unit 2/3 HP

Supervisor to the HP Manager dated April 24, 1986, which observed

that an extensive number of plant systems might contain fuel

fragments, that no controls specific for dealing with fuel fragments

were being implemented for work on these systems, and called for a

task force to address and eliminate the fuel fragment problem.

The inspectors were informed by the licensee's staff that a task

force to address the fuel fragment problem was not instituted until

December 1986, that a formalized program to control fuel fragments

during work on potentially contaminated systems was not instituted

until January 5, 1987, and that the majority of HP technicians did

not receive training in the specialized techniques needed for

detecting fuel fragments until December 1986 and January 1987.

The inspectors reviewed shipping documents which recorded the

transfer of ten fuel fragments from the licensee to a contract

laboratory on March 25, 1986. The ten fuel fragments, ranging in

size from 220 microcuries to 6800 microcuries, were recovered from

the fuel handling building. A fuel fragment of 100 microcuries will

produce a contact dose rate of about 300-900 rad /hr depending upon

the beta energy, age of the particle a,1d calculational technique.

Discussions with the licensee's staf f also revealed that 20 to 25

other large fuel frag'nents, whose activities were not determined,

were removed from the floor of the fuel Handling Building (FHB)

during the cleanup after fuel reconstitution. The insptctors were

also informed by the licensee's staff that perhaps hundreds of

smaller fragments whose activities were not determined were also

found at this time in the FH8. The inspectors noted that the

statistical analysis, presented by the licensee to support their

conclusion that no fuel fragment sufficient 1/ large to produce the

exposure in question was present in the areas which the worker

entered, neglected to include the largo particles removed from the

FHB and to consider the communication between the Reactor Coolant

System and the Reactor Coolant Pumps and the Spent Fuel Pool and the

Crud Tank System. The inspectors also noted that a formal tracking

.-

15

system to document the number and size of fuel fragments was not

established until January 2, 1987.

In view of the findings presented above, it appears that the

licensee's conclusion that: "No source capable of delivering such a -

dose were available within a vanishingly small probability" is

invalid.

l

C. Work Activities and Surveys

The inspectors reviewed the Radiation Exposure Permits (REPS),

'

numbers 76234, 90253 and 90254 which controlled entry of the workers

1

to the restricted area while wearing the TLD in question. The REPS

were found to be routine in nature, they contained no instructions

which would alert the worker or technician to the potential for fuel

! fragments within the systems being worked and they provided no

special instructions which would ameliorate the hazard from fuel

.

fragments.

.

'

. When questioned by the inspectors, technician "A," who had been the

responsible technician on October 6, 20 and 21 covering the jobs of

2

the worker in question, stated that he had not received, at the time

of the potential event or subsequently, the specialized

instructions, which had been provided to others, needed to detect

1 fuel fragments; that no specialized controls had been inn. ployed

i during the jobs which recognized the hazard from fuel fragments and

that the special survey techniques, needed to distinguish a fuel

fragment from activation product contamination, were not employed.

Although the licensee's staff could locate records of radiation and

j contamination surveys taken before and after the jobs in question,

they could produce no records of surveys taken of the areas or

'

components on which the mechanic worked during the period he was

wearing the TLD. The licensee's staff located the records of two

.

air samples taken during the period at the jobs in question. Based

! on their recollections, the workers and technicians invalved Gated

that only teletector measurements were taken during actual work on

the Reactor Coolant Pump seal and heat-exchanger / gasket replacement

and that these indicated maximum gamma levels between 5 and 10

rem /hr. They also stated that open and closed window R0-2

measurements were taken during the Crud Tank Pump repair and that,

as best the technician could recall, the meter never went off scale

on the 0-500 mR/hr range when components were surveyed and that the

meter never went off scale on the 0-50 mR/hr range when the workers'

gloved hands were surveyed.

1

The inspectors note that a teletector is a rugged, high range

geiger-muller survey instrument with a telescoping probe used for

measuring high gamma radiation fields and that it is insensitive to

beta radiation on the higher ranges. The R0-2 is a general use

ionization chamber survey instrument with a thin window which allows

detection of beta radiation and is equipped with a sliding metal

shield which can be used to eliminate the low energy beta

contribution from the response. The R0-2 can thus be used to

1 estimato the beta or surface dose rate as opposed to the deep dose

,

1

. - .

'

,-

16 +

a t

.

j rate by taking a window opened and a window closed reading and

applying a correction factor. The correction factor is dependent on '

.

the energy of the beta particles being measured the distance from

the source to the detector and the physical size of the radiation

source.

At NRC's request, a consultant laboratory made a series of

measurements of a fuel fragment, identified as No. 7, provided by

the licensee on March 25, 1986. This approximately 80 micrometer -'

speck of irradiated fuel was found to contain about 153 microcuries

of mixed fission products on April 6, 1987. The major isotopes

included Ce-144, Pr-144, Ru-106, Rh-106, Sr-90, Y-90, Cs-137, ,.

Ba-133, Pm-147 and Nb-95. The laboratory calculated the dose rate

to one square centimeter of skin through 7 mg/cm2 to be 432 rem /hr

if the speck were in contact with the skin. The dose rate measured

by an exo-electron technique was 215 rad /hr as close to the speck as

possible.

Using a large volume ion chamber (Eberline Mooel R0-2A), the

following measurements were made and the instrument response

recorded:

Shielded through Two Pairs of

Unshielded Rubber Gloves and One Cotton

Distance Window Open Window Closed Window Open Window Closed

Contact 6.0 R/hr 1.2 R/hr 2.8 R/hr 0.56 R/hr

10 cm 500 mR/hr 130 mR/hr 420 mR/hr 94 mR/hr

30 cm 61 mR/hr 15 mR/hr 56 mR/hr 11.7 mR/hr

The diameter of the R0-2A and R0-2 is about 7.6 centimeters.

Measurements were made as the instrument was moved in 0.5 centimeter

increments from directly over the speck, at contact, to one side.

The results are shown below:

Displacement of Source

from the Center of the Window Open Window Closed

Detector in Centimeters R/hr R/hr

,

0 6.2 1.0

0.5 6.2 1.0

1.0 6.0 0.98

1.5 5.9 0.95

2. 0 5.8 0.88

2.5 5.5 0.80

3.0 4.5 0.67

3.5 2.0 0.3

4.0 0.2 0.08

This experimental data indicates the extreme position and distance

dependence to be expected when using a hand held ion chamber to

survey for irradiated fuel specks.

.

-

~

!- 17

o If specks are located in areas of high background radiation, only

f deliberate and careful survey techniques could be expected to

l identify irradiated fuel fragments of this size.

The inspectors observed that the licensee's final report contains an

analysis of the maximum size of fuel fragments that could be present

during the work in question based on survey record data taken before

and after the work and the radiation levels as remembered by the

technician involved. The licensee's evaluation fails to take into

account that beta radiation from fuel fragments can be easily

shielded by small thicknesses of metal from piping or by a worker's

hand and that the presence of fuel fragments within a system or on a

,

worker's hand would not be observable, as noted above, unless

!

extraordinary surveys were made during the work and the technician

l involved had the knowledge and skill to detect them.

In view of the findings presented above, it appears that the

licensee's conclusion that: " Extensive radiation and contamination

surveys failed to detect any such sources" is not a valid basis for

concluding that sources of radiation sufficient to cause the

exposure were not present.

10 CFR 20.201(b)(1), Surveys, requires that each licensee shall make

j or cause to be made such surveys as may be necessary to comply with

the regulations in this part.

During the work on October 6,'8, 20 and 21, 1986, involving the

, reactor ccolant and crud tank pumps performed by worker "A" while

wearing the TLD in question, the licensee failed to make such

surveys as were necessary to comply with the dose limit expressed in

20.201(a), in that worker "A" received a dose to the right hand on

the order of 512 rem.

,

Failure to make such surveys as are necessary to comply with the

l regulations is an apparent violation of 20.201(b)(1). (86-37-05)

D. Medical Evaluation of the Worker

When the licensee first brought this event to the attention of the

NRC, the NRC's medical consultant contacted the licensee's physician

to confer on what physiological effects might be observable from

large radiation exposures to the hand of an individual. As the

worker involved was not examined until more than eight weeks after

the potential event, the window of opportunity had passed for

observation of physical effects such as erythema, which can occur

due to dotes to the skin of 200-600 rem between 1 and 2 weeks after

exposure and dry desquamation (flaking) which can occur due to doses

between 800-1100 rem, see: Extremity Monitoring: Considerations

for Use, 00simetry Placement and Evaluation, NUEEG/CR-4297 PNL-5509.

The licensee's examining physician observed no physiological effect,

that would have been indicative of an exposure greater than 1300 rem.

l such as moist desquamation or ulceration. When questioned by the

I inspectors, worker "A" stated that he did not recall any reddening

of his hand but that he did recall an episode of dry scaling on his

l

18

hand in about November 1986 but that he does occasionally

experience periods of dry scaling and took little notice of it.

The licensee's final report documents that the licensee's physician

I obtained a blood sample from worker "A" which was analyzed by a

nationally recognized authority for anomalies that might be observed

as a result of a large radiation exposure. The blood sample report

stated:

"We observed only two cells with dicentric chromosomes in our

cytogenetic analyses of 500 metaphases from lymphocyte cultures

from...(worker "A")....The distribution of dicentrics was

"overdispersed" in that one of these two damaged cells

contained two dicentric chromosomes. Such findings'could be

observed if the majority of...(worker "A"s)... circulating

.

lymphocytes had not been exposed to radiation, while a small

! proportion had received an excessive radiation dose. Thus our

cytogenetic findings corroborate exposure data from his

physical dosimeters which indicate that he may have received a

localized over-exposure of one hand, but that he did not

receive a clinically significant whole body dose."

l When a noted authority on the hematological effects of radiation was

l contacted by a Region V health physicist, the authority stated

that the noted dicentrics were not inconsistent with a large

i

localized exposure but such anomalies would have had an extremely

I

small chance of being observed due to the small volume of blood in

the hand.

In view of the findings presented above, it appears that the

licensee's conclusion that: "No conclusive medical evidence of such

l

an exposure was found" fails to recognize that the window of

opportunity for physiological observations was missed and that the

'

cytogenetic findings, although inconclusive, are consistent with a

partial body exposure of this magnitude.

E. Dose to the Worker

10 CFR 20.101(a) limits the total occupational radiation exposure to

the hands of an individual in a restricted area to 18.75 rem per

calendar quarter.

The Branch Chief and the consultant dosimetry expert determined,

from their visit to the dosimetry vendor, that there was no reason

to conclude the TLD in question did not function properly and that

the light output observed was consistent with a large dose of

ionizing radiation.

The inspectors determined that small intense sources of radiation,

fuel fragments, were present at the licensee's facilities; that some

of these particles exhibited sufficient activity to produce a dose

of the magnitude observed in a very short period of time; and that

the components on which worker "A" labored could have been

contaminated with such particles.

_

'

-

19 .

.

Lacking radiation or contamination survey records, the inspectors

determined, from extensive discussion with the workers and

technicians involved, that the surveys taken, as recalled, do not

provide conclusive evidence that a fuel fragment was not present

during the reactor coolant and crud tank pump work. In addition,

the technicians involved had not received the training needed to

detect such particles and the technicians did not have sufficient '

understanding of the properties of fuel fragments to determine if

they were present and to take action to protect the workers from

them.

Therefore, it appears that a maintenance worker received during the

fourth calendar quarter of 1986 a cumulative dose to the right

hand on the order of 512 rem while performing maintenance activities

in the restricted area.

Failure to comply with dose limits is an apparent violation of

20.101(a). (86-37-06)

V. Licensee Actions in Response to the Fuel Fragment Problem

As previously noted in this report, as a result of the Unit 3 Cycle 1

refueling outage, the licensee had, prior to identification of the 512

rem exposure, begun to establish a formal radiation protection control

program specifically to address the fuel fragment issue for the Unit 3

outage scheduled to begin in January 1987. ,

On December 22, 1986, the Health Physics Manager issued a memorandum to

site management titled: A Station-wide Program for Irradiated Fuel

Particle Control. This memorandum identified specific points to be

addressed by the Technical, Operations and Maintenance Support,

Maintenance, Operations, Planning and Control, Training and Health

Physics Divisions. The key points included: identification of all

systems containing fuel particles; determination of actions to prevent

further addition of fuel particles, transfer of existing particles to

other systems and cleanup strategy; improved fuel performance and

reconstitution programs; specialized maintenance planning; specialized

training; and additional radiation protection controls.

A general employee education handout titled: Facts About Irradiated

Fuel Fragments and How to Protect Against Them, was issued to all workers

on December 26, 1986, and incorporated into the formal General Employee

Training program performed as a requirement for restricted area access.

During the first week of January 1987, the specific radiation protection

procedures establishing a three-zone control approach were issued.

In the licensee's February 22, 1987, revision of LER No.86-015, the

licensee stated in part:

"Notwithstanding that we conclude that the overexposura did not . i

occur, action has been taken as if it did occur. This action -

includes the following measures:

.

_

., ,c_ . _ . , .r --,. _ _ _ _ _ - - , - . _ _ _ _ . - - - . - - _ _ . , . . -

- - . , __.

-

~

'

20

"1. The 512 rad extremity exposure report will be included in the

l individual's record as a special entry. In order to avoid

I

penalizing the worker in his future employment, the record will

also reflect the existence of the referenced report.

"2. The SCE program for detecting small radioactive particles and

for controlling exposure to them, already considered by SCE to

l be one of the strongest in the industry, was further enhanced.

l

This program includes:

" Extensive, mandatory use of exceedingly sensitive fixed

instrumentation (frisking booths) for the detection of ,

- personnel contamination;

"Special training (including hands-on laboratory

exercises) in radioactive ) article characteristics and

survey techniques for all lealth Physics Technicians;

" Oral and written indoctrination of all managers, first

line supervisors and workers in the special problems

associated with radioactive particles, including the

methods each person must employ to protect himself; L

"Special procedures to assure detection and control of

radioactive particles which feature the establishment of

clearly identifiable zones, to demark and contain such

particles, surrounded by clearly identified buffer zones

(or solid physical barriers) which are surveyed frequently

to verify that control is being maintained;  :

" Maintenance and wide publication of a radioactive .

particle census during outages to maintain Station  !

awareness;

l

! "The establishment of a Task Force to recommend and

l implement action to minimize the future production and

j movement of radioactive particles.

"3. Action has been taken to eliminate deficiencies in the vendor's

system for reporting anomalous exposures and in the Station's t

procedures for receiving and verifying routine electronic data

transmissions from the vendor. A change to our contract with ,

the vendor now mandates vendor compliance with previously

existing reporting procedures and that TLD chips which exhibit

anomalous high readings be promptly isolated, identified and ,

delivered to SCE with a full report of the results obtained." ~

During the NRC March 16-20, 1987, visit, the inspector confirmed that the <

General Employee Training includes a handout and video presentation on

fuel fragment issues. The inspector observed that two PBM-200 frisking

booths were being put into operation just outside the main restricted

area access point and all individuals were being provided a handout

titled: Information About Personnel Contamination and Friskina. The

handout explained actions workers should take to ensure they are free of

,

_ _

21

-

contamination; why the voluntary PBM-200s had been made available outside

f the restricted area; the establishment of a " Radiological Concerns

i

Phoneline;" and the safety significance of personnel exposure to

l irradiated fuel fragments.

The inspectors met with the Irradiated Fuel Particle Task Force

Chairperson and reviewed the action item status report of the March 10, '

1987, meeting. The task force is composed of first line supervision and

engineer level personnel from the various divisions. The chairperson

stated that he spends about one half of his time on task force

activities. Twelve action items were considered closed and eighteen open

at the time of this inspection. The closed items included six directly

related to training and the radiation protection procedures as described

above. The remaining involved use of a spent fuel pool skimmer during

refueling; increasing availability of the spent fuel pool cleanup system;

participation in the Combustion Engineering Fuel Users Group; and

consideration of irradiated fuel fragments in planning work activities.

Several key open items include: identification of systems containing

fragments; preparation for future fuel reconstitution; and identification

of systems to be cleaned.

Review of the licensee's fragment inventory and tracking report for the

period from January 2, 1987, through February 26, 1987, indicated 92 new

fuel fragments (composed of isotopes indicating recent exposure in the

core), 155 old fuel fragments, 51 ruthenium particles, 84 crud and 42

cobalt particles had been found and analyzed. One hundred and forty of

the specks were found on personnel or their clothing. The activity of

these 140 specks ranged from 0.001 microcuries to 1.249 microcuries.

Nineteen of the specks were detected with hand held friskers and ranged

from 0.002 to 1.249 microcuries, the remaining 121 were detected by the

PBM-200s. Sixty-two specks ranging from 0.199 to 21.53 microcuries were

detected from non personnel sources.

The inspectors discussed the irradlated fuel particle control program

with several workers including six llealth Physics Technicians. All the

workers seemed familiar with the program. Several workers were concerned

( with the consistent discovery of specks outside the zone controlled

areas. The workers felt that discovery of specks on personnel at the

PBM-200s indicated that the control program is not fully effective,

j Basad on the discussions with the six llealth Physics Technicians, the

'

inspector advised licensee management that one technician exhibited

excellent knowledge of the program and techniques to identify and control

l specks. Three technicians demonstrated an acceptable level of knowledge

and two technicians appeared to require additional training on survey

l

procedures.

The inspectors requested to review the dosimetry record for the

individual with the 512 rem hand exposure. The computer record did not

reference the 512 rem dose. The licensee representative stated that they

l plan to footnote the file indicating a copy of the evaluation is

available for review but not to show a dose of 512 rem for the fourth

quarter 1986 hand exposure.

l

'

22

l

l

l Based on the above observation, the inspectors found the licensee's

program to be adequate. Three areas were presented for the licensee to

consider:

l

'

There appears to be a significant' mismatch in resources allocated to

l the problem. It appears a great deal of effort is being spent

providing radiation protection measures while far less effort is

!

going into the task force effort to remove the source of activity.

,

More comprehensive radiation surveys need to be considered in work

l

areas and for people leaving work zones when they believe they are

'

contaminated.

• The licensee should evaluate the effectiveness of training provided

to the radiation protection technicians.

These points were discussed at the exit interview on March 20, 1987.

No violations or deviations were identified in this area.

VI. Exit Interview

!

'

The inspectors met with the licensee representatives denoted in Paragraph

1 at the conclusion of the site visit on March 20, 1987. The scope and

findings of the inspection were summarized. The licensee representatives

were informed of the apparent violations of NRC requirements discussed in

this report.

In regard to the apparent violations noted, the Vice President and Site

Manager stated that the Commission bears the responsibility to reasonably

enforce their Regulations and that the good faith efforts of SCE should

. be recognized. The Vice President and Site Manager continued that SCE's

l evaluation of the 512 rem exposure represents a large allocation of

l resources and that their conclusion is the most reasonable that could be

! reached based on the extensive research performed. Additionally, he

stated his belief that the SCE fuel fragment control program represents

i the state-of-the-art in the industry today and that their extraordinary

!

I

efforts should not be rewarded with Notices of Violations when other

programs, which probably have similar problems, are not being cited

,

because they are not as diligent as SCE.

l

l

l

1 l

l

l

l