ML20212H616

Evaluation of Reported High Exposure to Extremity TLD 80365 in Oct 1986

ML20212H616
Person / Time
Site:	San Onofre
Issue date:	03/03/1987
From:	Bray L, Donnelly E, Warnock R SOUTHERN CALIFORNIA EDISON CO.
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ML20212H615	List: ML20212H616
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NUDOCS 8703060170
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/m Iv) EVALUATION OF THE REPORTED HIGH EXPOSURE TO EXTREMITY TLD #80365 It. OCTOBER,1986 ggg PREPARED BY: /O" Richard V. Warnock Yb h. u b Elizabeth H. Don ly [bv A nj r Lin G. Br ' Nb ark'M APPROVED BY: '( ~>^ 3!%[ ....,_ Re r J. W" ' f Ma r, Health Physics D sfon i SOUTHERN CALIFORNIA EDISON COMPANY ~ San Onofre Nuclear Generation Site G703060170 870303 ADOCK 05000362 PDR PDR S O L

TABLE OF CONTENTS I. EXECUTIVE

SUMMARY

II. MEDICAL EVALUATION III. BACKGROUND DEVELOPMENT f A. WORKER CHRONOLOGY B. TLD RING NARRATIVE 1. THERM 0 LUMINESCENT 00SIMETRY 2. SAN ONOFRE TLD RING CHRON0 LOGY 3. DOSIMETRY VENDOR TLD RING CHRONOLOGY IV. ALTERNATIVES CONSIDERED 1. CAN IT BE CONCLUDED THAT THE RING ALONE, AND NOT THE INDIVIDUAL, RECEIVED THE REPCRTED EXPOSURE? A. TAMPERING () B. INADVERTENT EXPOSURE 2. WAS A RADIATION SOURCE OF SUFFICIENT OUTPUT PRESENT? A. MINIMUM ACTIVITY REQUIRED B. RCP SEAL WORK C. CRUD TANK PUMP WORK 3. WAS THE EXPOSURE REPORT VALID? A. PROCESSING ERROR OR ANOMALY B. VENDOR WEAKNESSES C. REPORTED OUTPUT AND RESIDUAL D. OTHER TESTS V. CONCLUSION VI. ACTION VII. ATTACHMENTS 4

I-1 I. EXECUTIVE

SUMMARY

r3 \\v) During October 1986, an SCE Maintenance worker wore two ring Thermoluminescent Dosimeters (TLD) provided by a vendor TLD service. The rings were worn on six separate occasions during routine maintenance work. Although the individual's whole body dosimetry indicated 114 mrem gamma, one of the two ring TLDs indicated an apparent right hand extremity exposure in excess of the 18 3/4 Rem / Quarter regulatory limit. The TLD worn on the left hand did not show any significant exposure (160 mrem). The TLD service reported all October TLD results on November 13, 1986 to SCE via electronic data transmission. Due to an error in the receiving SCE computer program, the reported exposure was reduced to a much smaller value. It was not until December 11 that the error was detected through comparison with a follow-up written report supplied by the vendor on November 17. When contacted, the vendor's night shift personnel stated that their recorcis indicated the reported value to be accurate. On the morning of December 12, it was possible to verify with the vendor's technical expert that the reported value was believed to be valid. As a result of this contact it was determined that sufficient preliminary information existed to believe that an extremity exposure in excess of regulatory limits might have occurred. Accordingly, the matter was reported via the Emergency Notification System pursuant to n 10CFR20.403(a)(1). U A Unit 3 Licensee Event Report (86-15) was submitted to the NRC on January 12, 1987. Several telephone contacts were subsequently used to keep the Region V office of the NRC appraised of progress in the investigation. From time to time, copies of a few of the attachments to this report were provided to the regional office and the Resident Inspector. i The individual was restricted from further exposure during the quarter. i l He resumed his normal activities on January 1,1987. Extensive medical l evaluation was promptly performed. The medical findings were negative or inconclusive. There has been no physical indication of exposure to l the individual's extremity since the initial evaluation. 1 In the course of the investigation it was found that the vendor was unable to reproduce the effect, (a " residual" of 11.48%) which he reported to be his basis for confirming the reported exposure as valid. In a test conducted by San Onofre, one hundred and seventy-two rings were exposed to beta, gamma, neutron and irradiated fuel fragment radiation. Doses delivered were in the range of 10 to 10,000 rad. In no case did the residual exceed approximately 2% when processed by the vendor using the same TLD machines which had been used to read the ring TLD in question. Ob

I-2 Outside consultants and other TLD processors were contacted. All ,,(d information reported back was consistent with the San Onofre test ) findings. One instance was found where another processor had evaluated the same type of TLD chips in a series of cobalt 60 exposures that ranged from 10,000 rad to approximately 100,000 rad. These data show increasing residual as a function of dose and indicated a residual of 11.48% would be observed at a dose of about 65,000 rad. It was also learned that the vendor failed to use his " read down" procedure which is normally employed to verify that the observed response is actually due to radiation exposure. Instead, only one additional reading was taken and then the TLD chip was thrown away. Accordingly, it is concluded that the exposure report was invalid. This conclusion is based on the following co-siderations: 1. The residual reading was unreasonable and unreproducible in the dose range reported; 2. No sources capable of delivering such a dose were available within a vanishingly small probability; 3. Extensive radiation and contamination surveys failed to detect any such sources; and, 4. No conclusive medical evidence of such an exposure was found. O V Additional research aimed at confirming whether the ring was exposed during storage and transfer and whether the reported result could have been caused by chemical agents was conducted. No basis was found for concluding that the ring, but not the individual, was exposed; nor was it possible to demonstrate the observed effect was a result of exposure to chemicals. Although it was concluded that the report was not valid, the exposure reported by the vendor will be placed in the individual's record as a special entry. O

II-1 ( _ II. MEDICAL EVALUATION 'v' The individual was interviewed by Dr. Leider, San Onofre Medical Director, and R. V. Warnock at 0030 on December 13, 1986. Attachment II-1 is a transcription of the tape recorded interview. This was the first opportunity for an interview because the individual had been on regularly scheduled days off when the potential exposure was discovered. The individual is a 45 year old male Caucasian who is employed as a machinist at San Onofre. He is right handed, but uses either hand for many things. The individual stated that he always wore his ring dosimeters on his ring or center finger with the TLD element toward the palm of his hands. Review of NUREG/CR-4297, " Extremity Monitoring: Considerations for Use, Dosimeter Placement, and Evaluation" indicates that doses required for nonstochastic effects in skin are as follows: Effect Threshold Dose (rad) Erythema 200 - 600 Dry Desquamation 800 - 1100 Moist Desquamation 1300 - 2000 U!ceration 2000 - 2500 Prior to examining the individual, Dr. Leider reviewed these data and the potential effects of a 500 rad extremity exposure with Dak Ridge p Associated Universities REAC/TS medical personnel. V Examination of the individual's hands revealed no erythema or epilation visible to the unaided eye. Photographs (Figure II-1) taken on December 16, 1986 show the individual's hands. No evidence of radiation damage is present. When asked by Dr. Leider, the individual stated he had not noticed reddening of the skin on his hands, loss of hair, tingling, or any other discomfort. He stated that stress and nervousness, or possibly use of solvents, sometimes causes a rash, tiny blisters, and itching of his hands. The tiny blisters then dry and peel. This occurred once during the past 1 or 2 months and has occurred numerous times in the past 4-5 years. The individual went on to state that a bout of flu was his only illness in the past 2 months. He had the flu about 3 weeks prior to the December 16, 1986 interview. A medical history was taken and a physical exam was performed on December 21, 1986 by Dr. Leider; it revealed nothing abnormal about the individual. When asked about previous medical radiation exposures, the individual recalled being X-rayed for a broken arm and shoulder in 1957, for pneumonia in 1958, for annual tuberculosis checks from 1967-1974, and for severe leg and abdominal injuries suffered in a 1978 motorcycle accident. Efforts to document the magnitude of these exposures were partially successful. About 5.6 rad is estimated to have been received from X-rays in late 1978 (see Attachment II-2). A

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II-3 Part of the physical examination included drawing a blood sample for ('-) chromosome analysis at Oak Ridge Associated University's REAC/TS facility. Lymphocytes from the circulatory system are the cells which are sampled, cultured, and examined microscopically to detect cellular level defects indicative of radiation exposure. Lymphocytes have an average lifetime of about 1000 days. Some have a lifetime as short as 5-6 weeks while others survive for many years. This average lifetime of 1000 days places a practical limit on how far into the past one should go to evaluate prior radiation exposures. This limit is a function of the magnitude of the exposure and the time since the exposure took place. For example, Hiroshima and Nagasaki atomic bomb victims who were heavily exposed show that a portion of lymphocytes carrying radiation induced dicentrics can survive for up to 3 decades. A person with no radiation exposure above that from natural background is expected to show about I dicentric per 1000 lymphocytes. Two dicentrics in one cell for such persons occurs infrequently. Heavy smokers and persons who are occupationally or medically exposed to radiation are known to have a higher than normal background frequency of cells with dicentrics including cells with multiple dicentrics. The subject of the cytogenetic evaluation is a nuclear power plant worker with an occupational exposure of about 1.2 rad and a medical exposure of about 5.6 rad. He was a heavy smoker ( > 1 pack / day) for about 20 years, but ceased smoking about 15 years ago. The cytogenetic results (Attachments II-3, II-4) indicate the following: (,) A clinically significant whole body exposure in the range of 20-50 rads can be ruled out. Based on the observation of a dicentric frequency of 3 in 500 cells, we estimate an exposure equivalent to a whole body exposure of: 12 rad X-rays (3.4-26 rad range at 95% confidence) 19 rad Co-60 (7-38 rad range at 95% confidence) i I Based on the observation of 2 dicentrics in one cell and 1 dicentric in a second cell, the individual may have received a high localized exposure in the past. It cannot be ruled out that the l observed cell with two dicentrics resulted from previous i occupational or medical radiation exposure or past smoking habits. 1 When asked by R. V. Warnock, Dr. C. Lushbaugh of REAC/TS stated that two dicentrics in one cell was not a likely result from exposure of a small part of a finger to the reported radiation dose during a short period of time. He stated that he had observed celis with two dicentrics from persons who had received many X-rays following a serious abdominal or pelvic injury (see Attachment II-5). As noted above, the individual has such an exposure in his medical history. l l w I

II-4 Based on the individual's age (45 years), an annual exposure rate of ,T (O about 200 mrem / year, his occupational dose of 1.2 rad, and his special medical exposure of 5.6 rad, his cumulative lifetime exposure is about 15.8 rad. This is in close agreement with the equivalent whole body exposure shown in Attachment II-3. At the recommendation of Dr. Reynolds Brown, an NRC consultant, the subject's hands were examined under UV light. Dr. Brown stated this technique would reveal skin damage from radiation doses of > 300-350 R. The examination was performed as described by Dr. Brown. None of the effects described by Dr. Brown were observed by Dr. Leider. As part of his medical evaluation, the individual received a whole body count on December 15, 1986. Results are included as Attachment II-6; 4 they show no external or internal contamination present. Throughout the medical examinations, the individual was kept apprised of 4-the objectives, status, and results of the analyses. This was done to assist the individual in understanding the procedures and to allay possible concerns. He cooperated fully during the evaluations and stated he didn't believe he had received any large radiation exposure. To summarize, no conclusive medical evidence was found to indicate an excessive extremity exposure occurred. Had a radiation source caused the 512 rem reported exposure it must have delivered no more than 512 rad to the hand, since a higher dose to the hand would have shown some p observable effect. A source o.. the palm, for instance, could have V delivered 512 rad to the TLD ring, but would have delivered a dose to the palm in excess of that required to produce dry desquamation. No such effect was observed by the examining physician, and no sensations of discomfort were described by the subject individual. From the results of this section it can be concluded that no evidence of exposure was found, and no exposure scenario, other than one with the radiation source located directly over the extremity dosimeter, can be reasonably postulated. i O

III-1 III. BACKGROUND DEVELOPMENT A knowledge of several background topics is important to understanding of the issues, events, and principles relevant to this report. This section contains a detailed chronology of the individual's actions during each of his entries into the radiologically controlled areas while wearing the TLD ring. This section also contains background material on the theory and use of thermoluminescent dosimetry, the chronology of the TLD ring at San Onofre, and its handling while in the possession of the dosimetry vendor. Analyses regarding the validity of the reported exposure borrow substantially from facts detailed in this section of the report. A. WORKER CHRONOLOGY The subject individual, a machinist employed at San Onofre, was issued the extremity dosimeter in question in October of 1986. At that time San Onofre Unit 3 was shutdown for replacement of all 4 reactor coolant pump seals. During October, the subject individual wore the extra ilty dosimeter into radiologically controlled areas on 6 separate occas ans. The purpose of this section is to describe the details of each of these 6 entries. Particular emphasis is applied to details which may relate to pertinent radiological data, survey techniques, self-monitoring frequencies, and stay times. Table III-2, detailing the maximum p possible exposure durations and the reported associated radiation doses U for the entries detailed is provided. The entries described are in chronological order and fall into 2 separate categories. Three entries were made in support of the replacement of reactor coolant pump (RCP) seals at Unit 3 (see Figure III-1). The other 3 entries were made in support of repairs to the crud tank pump, located at the 24' elevation of the Units 2/3 Radwaste Building (see Figure III-2). The description of the events which occurred during those 6 entries was reconstructed from witness's written statements, computer records, and Station documents. ENTRY I DATE: October 6, 1986 RADI0 LOGICALLY CONTROLLED AREA IN/0UT: 0828/1421 AREA: Unit 3 RCP P-002 PURPOSE: Replace P-002 RCP Seal Heat Exchanger Gasket and Mounting Bolts On Monday, October 6, the individual was assigned as Lead Machinist for a 4 person crew designated to continue work related to the replacement of the P-002 RCP seal. Upon receiving his assignment, he tailboarded the job in the machine shop with the 2 machinists and I helper assigned to him, specifically designating which individuals would be working inside the RCP shroud. The work crew was organized such that the (n individual was located outside the shroud, on the RCP platform, where he could pass tools, set up rigging, and supervise the job.

III-2 After the tailboard, the crew proceeded to the 70' elevation Health O Physics control point, where they signed on to Radiation Exposure Permit (REP) #76234 (see Attachment III-1). The individual then went to the special dosimetry issue point to pick up the required STDR3 dosimetry packet (2 extremity TLD rings, 1 chest TLD badge, and accompanying high and low range pocket ion chambers) and full face particulate respirator. He placed the 2 firger rings issued on the ring or middle fingers of his right and left hands (chip toward palm), clipped the TLD/ Red Badge assembly to his shirt, logged into the radiologically controlled area (time: 0828), and proceeded to the 70' elevation Radwaste Building Health Physics control point. The crew was advised by the attending Health Physics Technician to check in with the Unit 3 Containment Health Physics Technician before entering. The crew then proceeded to the locker room, changed into modesty garments, picked up the required protective clothing (hood, booties, shoecovers, double coveralls, double rubber gloves) and logged into the Unit 3 Penetration Building. They then donned their protective clothing (except for the respiratory protection devices, which were not required to be worn until later), checked in with the Containment Control Point Health Physics Technician, and entered the Unit 3 containment. The crew then proceeded to the P-002 platform, donned their respiratory protection devices, and began staging the tools and lifting devices required for the job. The radiological conditions in the vicinity of p P-002 are documented in Attachment III-2. Attachment III-2 is a () radiation and contamination survey of the P-002 shroud area performed at 0900 on 10/6/86. The conditions in the area may be generally described as consisting of moderate surface contamination levels ranging from 20,000 to 360,000 dpm/100 cm2 (removable beta / gamma) and radiation levels in the 10-20 mR/hr range, with contact gamma radiation level readings of up to 80 mrem /hr inside the RCP shroud. Continuous Health Physics coverage was provided by experienced Health Physics Technicians who had covered similar evolutions earlier. Work progressed, with 2 of the machinists doing the heavy work near the RCP seal and the subject individual working on the platform passing tools and rounding up lifting devices. The tasks to be performed were removing the RCP spool piece, uncoupling the RCP seal heat exchanger, lifting it about 6 inches, replacing a gasket, lowering the heat exchanger, and bolting it back down. At 1155 the RCP seal heat exchanger bolts were removed and the device was lifted. At this time a 10 minute air sample was drawn by the attending Health Physics Technician. Analysis yielded a value of 1.01 MPCs for that sample (see Attachment III-3, a summary sheet upon which air sample data were logged after analysis). Radiation levels in the shroud increased to as high as 5 R/hr during the 20 minute period that the heat exchanger was lifted. With the subject working as a supervisor, "go-fer", and observer on the RCP platform the job was concluded at about 1330. The individual doffed his outer plastic coveralls and outer rubber gloves at the RCP platform step off pad and exited the containment.

III-3 ( ~ l l l r v. .y A f f e l-f' .T' 1 l (' %L FIGURE III-I (AB0VE) RCP P003 Platform Area i (BELOW) RCP Shroud ) i

III-6 L /.: j' 1;x i 5 Si: 'N jiI j' ~ 3 t / Y2 ... ~ 'f / s' N k ,, %I f x ~ ? F FIGURE III-2 (ABOVE) Crud Tank Pump Repairs December 1986 (BELOW) Crud Tank Pump, Room 217A December 1986 l l

III-5 At the containment control point he removed the rest of his protective f] clothing and performed a whole body frisk at the Health Physics Technician monitored frisking station (starting with his hands, upon which both rings v remained). Having noted no evidence of radioactive material, he returned-to the locker room area and monitored himself again using the PBM-200 " Beta Booth" (still wearing his rings). Once cleared, he then entered the locker room, removed his modesty garments, removed all of his dosimetry and locked it in his locker with his personal clothing. He then showered, dressed, took his dosimeters and proceeded to the 70' elevation control point. There he hand frisked himself and his dosimetry packet and logged out of the radiologically controlled area, noting that his low range whole body pocket ion chamber (PIC) read 80 millirem. He then returned his STDR3 packet to the special dosimetry issue point and went to lunch. As a matter of interest, the PBM-200 referred to above is a personnel radiation monitoring system designed to scan persons for minute quantities of radioactive material. The system employs 30 highly sensitive gas flow proportional counters. In October, 1986, several such devices were in use at the entrance to the Units 2/3 locker room and at the exit to the Units 2/3 radiologically controlled area PBM-200 usage substantially increased with the start of the Unit 3, Cycle III outage on January 2, 1987. Extensive testing has established detection efficiencies and minimum detectable activities for the PBM-200. Tests were performed utilizing both a i 1 E-3 microcurie fuel fragment and a 1.6 E-2 microcurie cobalt 60 particle, each located on top of TLD rings which were inserted into the hand ports of the instrument. Both caused the PBM-200 to alarm 140 times in 140 trials. l The hand friskers referred to are Gieger-Mueller (GM) tube, thin window, pancake probes linked to alarming ratemeters. Tests performed with a 1 E-3 microcurie fuel fragment confirmed the detection capability of the Unit by consistently causing the Unit to alarm (see Attachment III-4). ENTRY 2 DATE: October 8, 1986 RADI0 LOGICALLY CONTROLLED AREA IN/0VT: 0825/1400 AREA: Unit 3 RCP P-003 PURPOSE: Replace P-003 RCP Seal and Store Near Containment Hatch On Wednesday, October 8, the individual was again assigned to lead the same 4 I person crew. His assignment this time was to remove and store the old seal located in RCP P-003. The crew again tailboarded, signed in on their REPS, obtained their special dosimetry (which had been stored in bins for reuse) and respiratory protection devices, put on modesty garments in the locker room, collected the necessary protective clothing and tools, checked in with Health Physics, and proceeded to the P-003 platform. l l t

III-6 'The radiolorical cunditions in the vicinity of P-003 were quite similar to O those found at P-002, with the exception of slightly lower contamination O levels and higher (25-50 r:R/hr) general area dose rates created by a heavily shielded pipe (pressurizer surge line) located nearby (see Attachment III-5, a radiation and contamination survey performed the next oay and Attachment III-6, an area survey performed earlier on the 8th). At the platform, the 2 machinists who had previously worked inside the RCP, again did the heavy work of rigging and removing the already uncoupled and bagged RCP seal assembly. The individual and his helper assisted from the platform by passing tools and rigging chain falls. As the seal assembly was removed from the pump shroud, the individual helped guide it into the transport cart by pushing and pulling the bagged seal assembly with his hands, as did the other crew members ' ~ The crew then exited the platform with the seal cart, doffing their outer coveralls, outer gloves, and respirators, and transported the seal assembly to a laydown area near the containment hatch. The individual then exited the containment and the radiologically controlled area exactly as he had on Monday (including the whole body monitoring processes at the containment exit and at the PBM-200 located at the locker room entrance), noting the 60 millirem PIC reading before turning in his dosimetry packet and heading for lunch at 1400. During this entire entry, continuous Health Physics coverage was provided, monitoring functions were performed, and air samples were taken. No untoward readings or occurrences were noted. [ NOTE: Because of intermittent respirator use, Entry 2 is logged as 3 separate, consecutive entries. These data indicate the individual worked in Unit 3 Containment (general area) from 0825-J120, on P-003 platform from 1120-1230, and again in Containment (general o area) from 1230-1400.] O ENTRY 3 DATE: October 9, 1986 RADIOLOGICALLY CONTROLLED AREA IN/0VT: 0818/0919 AREA: Unit 2/3 Radwaste Building PURPOSE: Receive New RCP Seal and Transport to Containment On October 9, the individual was assigned to the ongoing Unit 3 RCP seal replacement work. A malfunction had temporarily interrupted the availability j of supplied breathing air to the RCP platforms and therefore the individual was assigned to work outside containment. To do so, he signed in on REP

1. 90253 (see Attachment III-8, which also required an STDR3 packet), went through the entry process and donned modesty garments.

He proceeded to the 37' elevation Truck Bay at the rear of the Radwaste Building and assisted in receiving a new RCP seal, loaded it into the transfer cart, and transported it to the Unit 3 Containment Control Point. His services no longer required, he returned to the locker room and repeated the shower-dress-frisk-logout sequence. He exited the radiologically controlled area at 0919 having received no measurable dose (by PIC), turned in his dosimetry packet, and did i ( not return that day. l l ~

III-7 4 i ENTRY 4 (] i V DATE: October 20, 1986 RADI0 LOGICALLY CONTROLLED AREA IN/0VT: 0812/1107 AREA: Room 217A Crud Tank Pump. Room r PURPOSE: Disassemble and Repair Crud Tank Pump On October 20, 1986, the individual and another machinist were assigned to repair the Crud Tank Pump (CTP), located in Room 217A on the 24' elevation of the Units 2/3 Radwaste Building. The individual tailboarded the job in the 1 i Machine Shop, signed in on REP #90254 (see Attachment III-9), checked out his i STDR3 dosimetry packet, donned his rings, chest badge, and chest PICS, and signed into the radiologically controlled area at 0812. After discussing the job to be performed and the radiological conditions with the Radwaste Control Point Health Physics Technician, he arranged to have an Health Physics Technician who could provide continuous coverage meet them at Room 217A, and proceeded to the locker room to change.into modesty garments. He and the machinist then rode the elevator down to the 24' elevation and waited outside p the locked door to Room 217A for the Health Physics Technician. Shortly thereafter the Health Physics Technician arrived and directed the workers to begin donning their protective clothing while he verified the radiological conditions in the room. Using a portable dose rate meter and a portable frisker, the technician verified the radiological. conditions in Room 217A. Inside the bermed area containing the small pump contamNation levels ranged frem 30,000 dpm/100 car on the floor to 51 mrad /hr (smear) removable contamination on the exposed surfaces of the pump (see Attachments III-10 end III-11, radiation and contamination surveys of the CTP). Gamma radiation levels were about 10 mR/hr. After having verified the conditions carefully, the technician briefed tne l-workers on the conditions present and tailboarded the job with them. He then l checked their protective clothing (full protective clothing, extra plastic coveralls, double rubber gloves) and allowed work to begin. Working in j squatting, kneeling, and sitting positions inside the berm, the 2 machinists first uncoupled the motor from the pump. As they prepared to disassemble the pump, they then donned their respirators, and the Health Physics Technician l began drawing an air sample near the workers. They unbolted the pump, removed the impeller, and set the impeller on the floor inside the bermed area. The Health Physics Technician then surveyed the impeller with his dose rate meter l (both open and closed beta window), asked the workers to clean it with a Masselin cloth, and frisked the cloth. As the machinists in turn removed the impeller mechanical seal, bearing housing, and other pump internals tha l process of removal, survey, wipe, and survey was repeated. During this l process,.the Health Physics Technician provided additional sets of rubber j gloves so the mechanics could change their outer gloves after cleaning the i pump parts. He also repeatedly surveyed their hands while they were working (see Attachments III-12 and III-13 for amplification regarding the surveys l performed). Eventually, the machinists found that the source of the pump problems was a broken antirotation pin in the shaft, as well as, damaged j bearings and seals. Since they did not have the parts on hand to repair the pump they proposed to stop work. Before exiting the bermed area, they cleaned i the exposed pump and work area so that when they returned after lunch the l contamination levels would be low enough to preclude the use of respirators. I

III-8 The Health Physics Technician surveyed the area and found it to be lightly ("') contaminated (20-30K dpm/100 cm ). The workers then doffed their protective 2 U clothing at the step-off pad at the exit to Room 217A and moved into the 37' hallway to frisk. The subject individual performed a whole body frisk and found no contamination. He returned to the locker room, entered via a PBM-200 " beta booth", and proceeded to shower and exit as before. He exited the radiologically controlled area at 1107, noting a PIC dose of 20 millirem. ENTRY 5 DATE: October 20, 1986 RADI0 LOGICALLY CONTROLLED AREA IN/0VT: 1306/1458 AREA: Room 217A PURPOSE: Install New CTP Shaft Antirotation Pin After lunch on October 20, 1986, the subject individual and his accompanying mechanic returned to drill a hole for, and to install, a new shaft antirotation pin. After picking up their STDR3 packets and signing onto REP

1. 90253, they logged into the radiologically controlled area at 1306. They again arranged to meet their Health Physics Technician at Room 217A and went through the familiar pre-job procedures. At Room 217A they met the Health Physics Technician, donned their protective clothing, donned protective face shields, instead of respirators, and entered Room 217A to begin work. The Health Physics Technician surycyed the location on the pump shaft which needed to be drilled, found no significant contamination, and positioned a plastic bag to catch the shavings. With the subject individual's machinist friend mh going first, and the individual later taking over,to complete the job, the workers drilled a hole in the shaft, catching the tiny shavings in the plastic bag. As the Health Physics Technician surveyed during the job no untoward readings were noted. The workers then installed the antirotation pin to complete the job. The workers then exited the room, showered and changed and exited the radiologically controlled area at 1458. The subject individual received 2 nillirem to the whole body by PIC.

ENTRY 6 DATE: October 21, 1985 RADI0 LOGICALLY CONTROLLED AREA IN/0UT: 1349/1504 AREA: Room 217A i PURPOSE: Install New CTP Oil Seal On October 21, 1986, the 2 machinists again entered (at 1349) on REP #90253 to work on the Crud Tank Pump. Utilizing the same procedures and Health Physics Technician, they made a brief (about 15-30 minutes) entry into Room 217A to attempt to install a new oil seal. As the machinists attempted to reassemble the pump, they inadvertently damaged the oil seal and could not proceed. They exited, doffed their protective clothing, frisked, and left the radiologically controlled area at 1504 to go order new parts for the pump. The Crud Tank Pump was eventually repaired by other machinists. After the October 21, 1986 entry, the subject individual made no further entries into pQ the radiologically controlled area wearing his STDR3 dosimetry packet containing the TLD ring of concern. A printout of the computerized entry / exit records and the individual's written statement used to reconstruct the individual's movements are contained in Attachments III-14 and III-15.

. ~ III-9 The processed personnel radiation dosimetry results for the month of October, (%>) 1986 for the 4 workers who accompanied the subject on his 6 entries are displayed in Table III-1. A summary of the individual's entry and exit data is provided in Table IV-2. The table provides estimated possible exposure durations, assuming 30 minutes were required at the beginning and end of each entry to get to and from the plausible exposure location. As shown on Table IV-2 the longest possible exposure durations were found to be 293 minutes (4.9 hours) for the RCP work and 115 minutes (1.9 hours) for the CTP entries. 4 i O l I i l i V 1 l l

III-10 ~! v Table III-1 October Exposures Reported for Workers of Interest ['. Highest Extremity Max. Whole Body Dose Dose-mrem Person Gamma mrad P., eta mrem Gama RCP Platform Helper 170 (R. Hand); O 143(Chest) 456 (R.I;og$}' I s ) RCP Machinist #1 590 (R. Hand)' 116(R. Leg) RCP Machinist #2 !480 (R. Ankle) 200(R. Leg) 407 (L. Leg) Crud Tank Pump Machinist 90 (R. Hand) 0 (L. Leg) ' 37.(L. Leg) t i Subject Individual 511.99 Rad (R. Hand) r { 160 mrem. (L. Hand) 67(chest)* 114(chest) t i

• The minimum reportable dose for this dosimeter is abo'ut 40 mrad (Beta) j i

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jQ l y ^~~ ~ 7 y.g' III ~ e, .r. u, jq I'v/ Table III-2' Maximum Exposure Durations I Maximum Possible Exposure Durations Entry # y Initiating Event Terminating Event Interval l (estimated time) (estimated time) (minutes)- 1 i 1 Crn Arrived at P002 Entered PBM-200 at 293 .(0853)'- Completion of Work (1351) 2 Cr.ew Arrived at P003 Entered PBM-200 at 275 (0855) Completion of Work (1330) 3 . s Entered no radiation or contaniinated 'O, areas e 4 I Er tered Room '217A Entered P8M-200 at 115 (0842) Completion of Work 3 (1037) j . 5 - j' linteredRoom217A Entered PBM-200 at 61 (1336) Completion of Work ,r] V l (1428) ~ 6 Entered Room 217A Entered PBM-200 at 15 (1419) Completion of Work .< r l (1434) i I i s s t /' S

- ~, P III-12 B. TLD RING NARRATIVE _TLD ring 80365, the dosimeter of interest, has been'the subject of a-substantial body of research as a. result of the vendor's._ report. -While the data collected on similar dosimeters in the course of. this research has been - voluminous, consistent, and reproducible, the data on ring 80365 -itself is y conspicuously scant. No history, performance data, or glow curves were maintained-on the dosimeter by the vendor. Indeed, upon incompletely +' processing the ring, even the TLD itself was discarded by the vendor. Provided 'in this background subsection are discussions of gen'eral_thermoluminescent extremity dosimetry concepts,-a chronology of ring 80365 while at San Onofre, .and a description of the handling'of the ring by the vendor. Because of the lack of vital information from the vendor, and because of his failure to follow his own processing procedures, very few facts upon which any certain explanation for the reading might be based were available. b ~ With only a reported 512 X 10' nanoCoulomb initial output reading from a photocell and a 593 X 103 nanoCoulomb second reading to work with,.the task of investigating and postulating an explanation for the readings became difficult ~ and is -limited by the lack of data required-to determine if the light output l from the TLD was due to prior radiation exposure or some other causes such as contamination. The vendor did not follow his procedures for recording additional data in the case of the high indicated exposures for TLD ring 80365. 1. THERM 0 LUMINESCENT 00SIMETRY t~[ O. Dr. Phillip. Plato of the University of Michigan was retained to visit the vendor's site and review the vendor's systems for TLD receipt, preparation and processing. The results of his-first visit were covered in a report, dated December 31, 1986, and provided a detailed discussion of TLD processing by the vendor. Portions of the report are summarized here. Information from this report is used throughout this section. 7 Ring number 80365 was a one chip thermoluminescent dosimeter (TLD) in a -plastic ring holder. The chip was purchased from the Harshaw Chemical Company and was a standard Harshaw-TLD-100 element (natural LiF, 0.125" x 0.125" x 0.037"). Chips are placed into a depression in the ring body and a polyethylene window of 40 mg/cm2 thickness is sonically welded over the opening. An opaque mylar label, placed over the window, has a density 2 thickness of 9 mg/cm. This label contains several identification numbers, including customer account number, date of dosimeter issue,-a L binary identification code and a " participant" code. The last number is used by the customer to identify the dosimeter. There is no unique identification on the chip itself. Figure II-3 shows a TLD ring such as ring 80365 was, when issued. Natural LiF is sensitive to beta, photon and neutron radiation. It slightly over responds in the low energy photon (X-ray) range. It has a low sensitivity to light. There is some fading during the first 24 hours after irradiation; thereafter loss is only 1 to 2 percent. With a 49 mg/cm2 density thickness cover, the ring TLD should not respond well to low energy photons (X-rays) or low energy betas and would not exhibit light sensitivity. TLD chips, such as these, are relatively insensitive to heat and humidity. Cracks in the crystalline structure of the chip can cause abnormal responses. Also, chemical contamination of a TLD (eg., dirt, dust, salt, talcum fibers) is known to produce indications at radiation exposure when the TLD is processed. w.=. - -. - - - - -

III-13' 7. Thermoluminescent (TL) materials trap electrons that have been 4 iliberated through ionization and excitation in defects in.the c1 crystal lattice. When these TL materials are heated, the trapped i" electrons are released and return to a ground energy-state, emitting

light. The light output is measured and is proportional to the radiation dose absorbed by the TL material.

Every TL material has a i characteristic glow curve-(like a fingerprint) with one or more. o peaks. These' peaks are related to the energy level of the electron-traps in the crystal lattice. Contrary to most current practices, 4 ' glow curves are not recorded by the vendor who processed ring 80365. This eliminates an opportunity to gain valuable information which would have helped determine if the'TLD response was due to-radiation or.some other cause.. Availability of a glow curve would also permit an estimate of the time when the' exposure occurred. Such r estimates are made possible because.the glow > curve peaks decay at rates specific to each separate peak after irradiation. By ratioing the peak outputs,- the irradiation time can be estimated. I Natural LiF (the.most common TL material) has 6 energy peaks in its glow curve. The low energy peaks are the most sensitive to fading 4 (i.e., the electrons are released spontaneously, prior to heating). Therefore, most LiF readout cycles use a " preheat" phase that is not read (eliminating these-peaks). The' highest energy peak is not read out either, due to the high temperature the TL material must be brought to to reach this peak, and due to the fact that electrons rarely reach this energy level. This high level trap is filled when high linear energy transfer (LET) radiation impacts the material, or-the. crystal is saturated by a very high dose and no low energy traps are left. Usually, the middle range peaks are read out to assess dose. a f " Residual" is the term applied to light output that occurs when a chip is read for the second time without additional radiation exposure. (In the pr3 cess used by the vendor, the residual light output reported was measured following exposure of the~ subject chip to a known, sma_ll radiation dose for the purpose of calibration.) Residuals may.be observed if tne chip was not. heated properly during i the first read, if ~ electrons released from traps in the high energy peak fall to the lower energy peak after the first read and 4 subsequently emit light during the second read, or if chemical contamination of~a chip occurs. l-To read out their TLD-100 chips, the vendor which processed ring 80365 uses Harshaw Atlas readers. They process 70,000-80,000 " loose" chips from ring dosimeters each month. On October 1, 1986, the vendor put a new carbon dioxide laser heating system in place which employed one laser with a split beam for two readers. The 4-laser readers are much faster than gas heated readers since the heat cycle takes only I second per chip for the laser heated reader compared to 12 seconds per chip for standard gas heaters. The laser heated readers slowly took the load off of the existing nitrogen gas i heated systems and, by January, 1987, almost all TLD-100 chips were being read using the laser readers. The subject ring was read using the new laser heated reader. ~ w-s-. ~ w - -m,e es r-,m e w-,, e-we,.,r-wr- -,---,v.e, m-,, , we e ~ n ww-,,,-.w-nw~,-e--em w,,,g--,1.w-v-.v---,---e,-p--w e v' ~s v--,--------- -w asrm'v"-~~ 9-f '

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,v - y, s. - 1 ,s 7.. i ' f'3 g .. ja..i l,k h5l. -h,.4kk. 4 A r 9 hx.h>,l'$f'hk.:'f.D hk, Ed I .M, ' 4 j, ,4,. } v. 3 ,4 ,4 r,4 f.j., t 4,. M.. "g.L, . 0/g . i 4 - c., p' <,.g FIGURE III-3 i TLD Ring As Received From Vendor and Ready for issue

III-15 After a chiptis read out for dose information, it is annealed for 1 Lp hour at 400 C,-is washed in an alcohol bath, and is then sonically v sealed into a plastic ring for the next use cycle. All prepared rings are kept on a shelf in boxes prior to issue. If they have been shelved without being issued for more than 30 days they are removed from the ring holders, read out, alcohol bathed, and placed back in rings. This reduces background on the chips supplied to customers. When issued, labels are affixed and the rings are sent to the customer together with controls to measure radiation during shipment. Once returned by the customer, the rings are frisked for contamination. Then they are opened with tin snips and the TLD chips are.placed in a 50 slot processing holder. This circular holder is placed on a reader and the chips are read. One problem with TL material is that the variance in crystal size between chips causes variance in sensitivity between chips. Normally, element correction factors are generated to correct for this and other factors. But, with chips that have no individual identification, this is impossible. At this vendor, this problem is addressed by removing the holder containing chips that have just been read out, and, without removing the chips from the holder, irradiating each chip to a known dose, and reading out the chips a second time. This second read of a known dose gives each chip its own calibration factor in dose per light output reading. If the second read of an exposed TLD is abnormally high, a " generic" daily calibration factor is used to convert the chip response to dose. For high dose readings (>15 rad) the vendor generally employs a procedure which requires several more readings, referred to as " read-downs". If the read outs continue on a downward trend, the vendor believes this to indicate the badge was exposed to radiation. If the readings do not show a continuing downward trend, the vendor believes that chemical contamination is involved. After read down of a high dose, the chip is discarded because it is no longer useful for personnel dosimetry. Such chips are not useful because they continue to produce high background readings. For ring readings >25 rad, the vendor's procedures require immediate notification of the customer. No such notification was made to San Onofre personnel. 2. SONGS TLD RING CHRONOLOGY Ring TLD 80365 was prepared for October 1986 use by the vendor sometime during September, 1986. Preparation presumably included a 1 hour, 400 degree centigrade anneal after the previous use and readout, an alcohol rinse, and sealing into a new plastic ring. The unlabeled ring was stored by the vendor until SCE's order was filled.

III-16 Ring 80365 probably received its identifying. label during the third N(V week of September,1986 in preparation for shipment to San Onofre on September 23, 1986. Federal Express received the dosimeter shipment from the vendor on September 23, 1986 and delivered it to San Onofre on about the morning of September 24, 1986. These dosimeters were stored in the San Onofre TLD Lab until the morning of September 29, 1986. Ring 80365 and other rings were transported from the TLD Lab to a locked storage cabinet in Units 2/3 en grade 70' on the morning of September 29, 1986. Ring 80365 was removed from storage and placed in a STDR3 dosimetry packet (2 finger rings + 1 whole body badge) at about 0800 on October 6, 1986. This packet also included ring 80366 and Panasonic whole body badge 12088. The packet was issued to the individual for initial use during his October 6,1986, 0828 to 1421 radiologically controlled area entry (Entry 1) in which he worked on Unit 3 reactor coolant pump P-002. The individual returned the dosimeter packet when he checked out at 1421 and the-packet was stored in an individual, labeled drawer for future use. Ring 80365 was next used for the entry from 0825 to 1400 on October 8 (Entry 2) when the individual worked on reactor coolant pump P-003 in Unit 3 Containment. The packet, including the ring, was again stored at grade 70' under control of Dosimetry personnel after use. The individual was again issued his STDR3 packet on October 9, 1986 for an 0819-0918 Radwaste Building entry (Entry 3) in which he assisted in moving a new, never used reactor coolant pump seal from the truck bay to Unit 3 Containment personnel hatch. After this p use, the badge was returned to Dosimetry personnel for storage. The d individual entered the Radwaste Building on October 20, 1986 from 0812-1107 wearing ring 80365 (Entry 4). He worked on a crud tank pump. On exit at 1107, his dosimetry packet, including ring 80365 was surrendered to Dosimetry personnel for safe keeping. The individual returned and entered the Units 2/3 Radwaste Building from 1306-1458 (Entry 5) to continue his work on the crud tank pump. He was wearing his STDR3 dosimetry packet including ring 80365. On exiting the radiologically controlled area at 1458, the individual again surrendered his dosimetry packet to Dosimetry personnel for storage in the designated drawer on grade 70'. Final use of ring 80365 and the associated left hand finger and chest badge occurred from 1349-1504 on October 21,1986 (Entry 6). The individual again worked on a crud tank pump in the Units 2/3 Radwaste Building. Once relinquished to Dosimetry personnel at 1504 on October 21, ring 80365 and the other two dosimeters were stored in the designated drawer until they were transported to the TLD Lab at about 0800 on October 30, 1986. The dosimeters were frisked and found free of contamination before being taken into the SCE TLD Lab. Ring 80635 was stored in the TLD Lab from early morning on October 30, 1986 until it was shipped via Federal Express to the vendor on the morning of November 5, 1986. The vendor received the dosimeter on November 6, 1986 in the morning. Attachment III-16 provides a graphical summary of the location of ring 80365 throughout its known history. O

III-17 3. DOSIMETRY VENDOR-TLD RING CHRONOLOGY /OU When received by the vendor, the package containing ring 80365 was taken to a dedicated room used by the vendor for opening and frisking incoming dosimeter shipments. Ring 80365 and 646 other dosimeters from San Onofre were found free of contamination. Ring 80365 was probably stored in the processing room in a plastic box awaiting read out. The vendor indicates that ring 80365 was processed on the afternoon of November 10, 1986. Normally, processing of the ring involves cutting open the ring with tin snips to remove the chip. No abnormalities were recorded on the data entry for this chip. Position number 42 of a 50 position metal holder was recorded for - the chip along with ring identification label. Vendor records show that chip 80365 was processed on Harshaw Atlas reader AA using a laser heating source at 1540:12 on November 10 and that the photocell output was 0512-2 nanoCoulombs (nC)..The vendor procedure then required that the chips remain in the holder while it was exposed to 350 mrad in a strontium yttrium 90 irradiator in order to develop an element calibration factor (ECF) for each chip. This response (11.48% of the initial read) was so far beyond what was anticipated from the strontium yttrium 90 irradiator that an element calibration factor could not be developed. Instead, the daily calibration factor was applied to develop the dose of 512,000 mrem. Ten mrem was subtracted to give the reported 511,990 mrem v dose. The element from ring 80365 was thrown away by the vendor following its large response measured after irradiation to strontium yttrium

90. No attempt was made to examine the element carefully for-visible signs of contamination or structural damage, and the element was not read again before it was discarded.

Each batch of elements includes at least two quality control I elements that were irradiated to 300 mrad from a Cs-137 source. The i reported dose from these quality control elements must be within 15% l of 300 mrad in order for the entire batch to be acceptable. Each l-day that ring badges are to be processed, 4 calibration elements are j irradiated to 1000 mrad from the Cs-137 source. When these calibration elements are read, their average response in units of mrad /nC is calculated. This enables a daily calibration factor to be calculated in units of mrad /nC. If for any reason the actual calibration factor for a given customer's element cannot be determined, the average daily calibration factor will be used. l The quality control chips included with the TLD from ring 80365 were l within acceptable criteria as were the four elements processed in the morning which determined the daily calibration factor. l0 ~

y III-18 1 The vendor has La general policy for notifying a customer by. f. telephone as soon as a-high dose has been determined for a ring JJ badge. _In addition, a-customer can establish.their own policy for-f immediate telephone notification. The vendor reported that its general policy for immediate notification is a dose in excess of e 25,000 mrad. The specific policy established for San Onofre was 6,000 mrad.- For ~ some reason this policy was not followed in the Icase~of ring.TLD 80365. The vendor's representative noted that this had occurred through oversite. Vendor representatives stated'that, because the chip from ring 80365' } had a very large residual -reading, it was removed from service and. discarded. Contrary to-vendor procedure. additional read downs-were not performed to gather data which might have helped explain the L abnormally large residual reading. The opportunity.to expose and read the chip and to physically and chemically analyze the chip was lost. Based on his-first visit, Dr. Plato concluded that there were six { vendor weaknesses that contributed to the difficulties in trying to determine the cause of the large response. Probably, none of these six weaknesses caused the large reported dose. However, they combine to make it' difficult to pursue possible explanations of the high reading that' involved processing of the LiF element in question. Each of these six weaknesses is discussed below. t The first weakness was the general assumption by the vendor that a p. large dose was the result of intentional. spiking by the customer. The second weakness was the failure of the vendor to telephone San Onofre as soon as the large response was determined for ring badge no. 80365. Review of' vendor records revealed that the procedure for immediate notification was in the process of being implemerted, but for some reason the call'to San Onofre was not-made. -If the call had been made when the badge was read on November 10, everyone would have been in a much better position to investigate the cause of the large response than they-were on December 11 when San-Onofre first discovered the large reported dose. The-third weakness was the failure of the vendor to read the element from ring badge no. 80365 several times after the initial large response was discovered. This is part of the vendor's procedures c for handling elements that show a dose greater than 15,000 mrad. Data from multiple readings might have been useful to determine if the large response was caused by exposure of the element to ionizing radiation, or if it was caused by contamination of the element with a non-radioactive material. l ? i 1- ! O. l r - g ,b~,,m..w-,.y_,-,y-,mJ_,,,,,-.m._,,,_-,.,.-m-,yv,--,,,,,,., ,.-,,__,,_m ,.,. ~,. -,_,,.e.,.m.,-. .. -,,-,,m-,,.

III-19 The fourth weakness was the failure of the vendor to save the (9 element from ring badge no. 80365 once they discovered that the V element had apparently received a large dose. In Dr. Plato's opinion, this should be part of their procedures. In fact, the vendor discarded the element because it had received a large dose and was therefore not suitable to be kept in service. During Dr. Plato's first visit to the vendor's facility, he saw about two dozen elements in the discard box that had accumulated during the first half of December. Some elements looked good, but others had a frosty appearance, and one was broken in half. If the element from ring badge no. o0365 had been saved, and if the large response had been caused by a physical effect involving the element, there is a chance that careful examination of the element would have revealed the cause of the large response. Useful information could have been obtained from reading the element several more times, observing the shape of glow curves, irradiating and reading the element, and examining the element under a microscope. The fifth weakness was the vendor's inability to track the history of an individual element. This is an inherent problem with the use of loose Harshaw elements that have no positive' identification. In the case of the element from ring badge no. 80365, it would be helpful to know when the element was purchased from Harshaw, how good its initial response was, and how many times the element had been used prior to being sent to San Onofre in October, 1986. 3 The sixth weakness was failure of the vendor to generate glow curves J for the elements they process. Glow curves can be very useful in distinguishing a radiation induced response from a response caused by factors other than radiation, including factors traceable to the TLD reader. As a result of his first visit to the vendor, Dr. Plato did not identify any particular aspect of the vendor's process which would have itself caused the reported high exposure. On that occasion a vendor representative briefly showed Dr. Plato vendor developed data which he said indicated that the high residual reading of 11.48% was not out of line with what would be expected I from a 511.99 rad exposure. At that time, and based on this data alone, Dr. Plato felt that the 11.48% residual indicated that the l reported exposure value might, indeed, be due to radiation exposure I and this was reflected in his report. It was not until he had an opportunity to research this question further and to observe the r data being generated by the San Onofre test program that Dr. Plato ultimately concluded that the high residual indicated the initial response of TLD 80365, reported by the vendor as equivalent to l 511.99 rad, was not due to ionizing radiation. l O i O l l

III-20 In summary, investigation has been able to provide excellent detail ,_s ( ). as to the chronology of the subject TLD ring while at San Onofre. The history of the TLD chip before that point, however, is largely unknown. It's date of manufacture, previous uses, performance history, and other pertinent characteristics prior to this use were not recorded by.the vendor. For example, it is possible that the TLD chip had not been properly annealed following radiation exposure prior to its use at San Onofre. More significantly, the normally applied read down procedure and immediate notification of a reading in excess of 25 rad did not occur. Other vital information was lost because glow curves were not generated and high dose chips were routinely discarded, although the vendor saw only 5-10 chips per year which were reported to be above 100 rads. Only the high ~ reported initial output and the 11.48% reported residual stand as bases for investigation. ~' s_- l 1 I l [ t

IV-1 IV. ALTERNATIVES CONSIDERED To provide a basis for acceptance or rejection of the validity of the value reported by the vendor, the following basic questions were considered: 1. Can it be concluded that the ring, but not the individual, received the reported exposure? 2. Was a radiation source of suf ficient output present? 3. Was the exposure report valid? To answer the first question, the possibilities of intentional tampering and inadvertent exposure during storage and transfer were investigated. No basis was found for concluding that the ring, but not the individual, was exposed. To determine whether a source of sufficient output was credible, calculations were performed to establish the minimum source activity required under the known work conditions. Available evidence was analyzed to determine the probability of the presence of such sources. Review of the surveys performed and statistical evaluation of a census of all identified sources provide a basis for asserting that such sources were not present. n To determine the validity of the vendor's reported value, the bases for Ci the vendor's assertion were examined. The vendor threw the TLD chip away, precluding the possibility to examine it or to perform further tests on it. The vendor failed to follow its normal " read down" procedure beyond a single rereading of the chip. This made it inipossible to use the normally employed method for verifying that the exposure was due to ionizing radiation. The only remaining information, the so called " residual" light output, was reported to be 11.48% of the first reading. Extensive testing of the vendor's reported residuals on a large series of comparable exposures, examination of the vendor's residuals on significant exposures during the last quarter of 1986, and review of the findings of others with regard to residuals, demonstrates that the 11.48% value is not reproducible and clearly outside the bounds of a proper value for the reported exposure. Accordingly, it must be concluded that the vendor's reported value is not valid. Details of the analysis are reported in this section. b v

IV-2 .IV.1 CAN IT BE CONCLUDED THAT THE RING ALONE, AND (]. NOT THE INDIVIDUAL, RECEIVED THE REPORTED EXPOSURE? IV.1.A. TAMPERING To validate such a conclusion, it would be necessary to show that the ring had been exposed through intentional tampering or inadvertently while the ring was in storage or transfer. To demonstrate that the TLD was exposed at San Onofre as a result of tampering, the following conditions must be proven:

1) The dosimeter must have been deliberately removed from its container, exposed to a high activity source, and replaced;

2) There had to have been a break in the control of one of the high activity radioactive sources;

3) There had to have been a person on site who had the opportunity, 3

knowledge, and motivation to tamper with the dosimeter. As described in Section III, there was positive control of the dosimeter after it arrived on site until it was assigned to the worker on October 6, 1986. After being assigned to the worker, the ring was stored in a bin (No. 56 or 57) at the Unit 2/3 Dosimetry Access Control Point. The control point was always manned, but the bins and associated storage cabinets were not locked. The ring in question was stored with the ring s for the opposite hand and the whole body (chest) dosimeter. All three dosimeters were contained inside a plastic zip lock bag and were stored in the same bin until October 30, 1986, except while in use by the worker. The dosimetry packet was storad in this location without having been used by the worker for periods of-up to 10 days. It should be noted that the bins and storage cabinets for the dosimeters are now in a locked office to provide positive control over the dosimeters at all times while in storage. Also, evidence tape bearing l the worker's signature is now used on the zip lock bags to reveal any possible tampering. Sealed radioactive sources are maintained by the Health Physics Instrumentation Group and are stored in several locked cabinets in various locations on site. Of the sources available, there are several which could produce 511.99 rads over a 10 day period, but only 3 which could deliver such a dose in a period of a few hours. (Radiography sources are used on Site but are at all times under the direct control of the radiography contractor.) A person planning to tamper with a dosimeter would probably not know how long it would be until the worker l would need the dosimeter again. Therefore, only sources that could deliver 511.99 rads in a few hours were considered. l O I

IV-3 One of the three sources, a 130 Ci cesium-137, is located in Room 102. O The other two sources are 260 Ci and 30 Ci cesium-137, respectively, and are located in Room 105. All 3 sources are locked within shielded devices. The keys are stored in the HP key lock box. The source in' Room 102 is within a manually operated source storage device that was inoperable during October 1986. However, a determined person, with the keys and appropriate tools, could have exposed the source. To use one of the 2 high activity sources located in Room 105, a person would need one of the room keys and a source key. All of these could be obtained from the HP key lock box. Room 105 was manned by an HPI Technician every week day from 0800 to 1600 during the period in question. The presence of an unauthorized person would have been noticed and prohibited. It is likely, therefore, that the tampering would have to occur outside of these times. Attachment IV-1 provides a time grid which depicts the ring location history and the times Room 105 was unmanned. The overlapping times where the ring was in the bin at elevation 70', and when the room was unmanned are considered the most likely times for tampering. Therefore, any individual desiring to tamper with the dosimeter, must have been available on site during these times. One worker was identified who may have had the motivation and who, during /N an 8 d:y neriod, may have had access to the dosimeter and sources from ( 0600 to 0800 (see Attachment IV-2). With the participation of SCE Corporate Security, SCE Employee Assistance and FBI personnel, intensive interviews were conducted with the subject to explore motives, opportunities, and capabilities. The results of the interviews failed to provide any evidence that the individual was involved in tampering. I In summation, it must be concluded that both the dosineter and the necessary radiation sources were available to someone who had sufficient familiarity with the systems and conditions of work. An investigation concluded however, that no evidence of tampering could be found. l l O s

IV-4 s IV.1.B. INADVERTENT EXPOSURE Whereas tampering might have been performed using a relatively large 5 source for a relatively short period when the TLD was not being worn, inadvertent exposure might have occurred due to contamination of the TLD, its ring holder, or of items with which it was stored for much longer periods. The source in this case could have been quite small. Material is presented in Section III, Background Development, regarding the chronology of the TLD chip. This discussion begins with its preparation at the vendor's facility, progressing through its storage, transfer and use at San Onofre and concludes with its final processing at the vendor's facility again. Attachment III-16 presents related information in a graphic form. Attachment IV-3 provides details on the status of " controls," dosimeters that remained with ring badge 80365 during the indicated periods and received the same exposure. It also indicates the points in time at which surveys of the ring badge were conducted. Evaluation of the controls and review of survey data is useful in that it delimits periods during which inadvertent exposure was not likely. As far as can be determined, ring TLD 80365 was accompanied by ring 80366 (the other ring badge worn by the individual) from the time it was sent to San Onofre until the time that 80365 was thrown away. Ring TLD 80366 was processed and indicated an exposure of 160 mrem. Two other unnumbered rings were kept with 80365 during the same period, except between October 6 and October 30, 1986. When the ring TLDs were evaluated they indicated no exposure. Body badge TLD set 10288 was kept with 80365 at all times during the period of October 6 to October 30. However, it was worn on the body, some distance from 80365 during work. Evaluation of this TLD set indicated an exposure of 114 mrem gamma and 67 mrad beta. On three occasions, October 30, November 5 and November 10, all of the rings in the batch, which included 80365, were checked for contamination by frisking with a GM tube attached to a count rate meter. The first two frisks were performed at San Onofre, the other was done by the vendor. All surveys yielded negative results. On several occasions, including the end of the six work sessions during which the individual used 80365, the rings were surveyed and found clean by virtue of the fact that the individual used the hand counters which are part of the PBM-200 automatic personnel frisker. Information on the actual status of 80365 during the period prior to the time it was sent to San Onofre was not available from the vendor. The vendor's normal processing calls for TLD chips to be annealed at 400 degrees centigrade for 1 hour, to be washed in alcohol and mounted in a ring, and then to be boxed and stored, awaiting issue to a customer. Whether this process was followed for 80365, whether the annealing and alcohol wash were accomplished and whether control dosimeters were present to detect inadvertent exposure during the exposure period is not s known.

+ IV-5 r These gaps in information are unfortunate. If TLD 80365 had been O previously exposed to a chemical or other agent, or to radiation during handling or during use by another customer and if the anneal and alcohol l wash were inadvertently missed, a condition which produced the reported reading would be possible. i j 1 1 1 i l l i f a!O I l O l

IV-6 IV.2 WAS A RADIATION SOURCE OF SUFFICIENT OUTPUT PRESENT? ( s IV.2.A. MINIMUM ACTIVITY REQUIRED The only types of highly localized sources capable of delivering significant exposure within a short time period which have been identified at San Onofre are microscopic fuel fragments or cobalt 60 particles. In order for one of these particles to have caused the exposure to the TLD ring while being worn by the individual the following conditions must be satisfied: a) The minimum activity particle available in the work area must be of sufficient activity to produce the 511.99 rad exposure during the longest entry period (see Table III-2 for maximum estimated exposure durations). b) The activity level and location of the particle must cause negligible exposure to the TLDs located on the worker's chest and left hand. c) The activity level and associated observable exposure rate created by the source must be low enough to have been missed by the job coverage surveys performed. In reviewing the following section it will be found helpful to know that (] at San Onofre an individual assigned to a task involving significant U radiological conditions would pass across several boundaries on his way to work. First, he would encounter the boundary of the restricted area, which at San Onofre, coincides with the protected area boundary. At this point he would have to obtain his personnel monitoring device, a TLD body badge which is attached to an identification card, referred to as a " red badge." Only individuals who have the required training, including basic radiation safety training, have such badges. The red badge also incorporates a magnetic strip which activates the gates to the restricted / protected area. The individual would then proceed to a radiologically controlled area. To pass through the boundary to the radiologically controlled area, the worker would have to learn and comply with the provisions of a Radiation Exposure Permit (examples can be found as Attachments III-1, III-8 and III-9) and his status regarding additional training, accumulated dose and other requirements would have to be determined to bc satisfactory. If the individual were going to work in containment, he would also encounter a boundary at the entrance of containment where he would have to notify the Health Physics Technician in charge there of his Radiation Exposure Permit number and of the work he intended to do. Finally, he l would come to the boundary of the work area. Depending on radiological l conditions there, the area would be marked, barricaded or locked. Access to the work area is controlled by the provisions of the Radiation n Exposure Permit. U

IV-7 At Units 2 and 3 the locker room, within which workers change from their i i street clothing to modesty garments, is located within the radiologically 'd controlled area. In order to enter the locker room, one must pass through a PBM 200 whole body frisking booth. Also at Units 2 and 3, in order to exit the main radiologically controlled area, one must pass through another whole body frisking booth to be evaluated for contamination. The minimum particle activity required to produce the 511.99 rad exposure can be determined from the longest period the worker remained in the work area, the closest possible location of the source to the TLD, and the dose rate characteristics of the source. Since; 1) all protective clothing is monitored before issue, 2) the individual passed through a whole body frisking booth at the locker room exit prior to donning his protective clothing and received no alarms, and

3) the worker was monitored in a frisking booth for contamination following each work activity which required the use of protective clothing and received no alarms, it is assumed that the individual's TLD ring could not be close to a radioactive source prior to entry and after leaving the work area.

As has been noted in Attachment III-4, the PBM 200 whole body frisking booth is a highly sensitive system used for promptly detecting radioactive contamination on anyone who enters it. To activate the p counting cycle, the individual places each hand into a separate opening V and starts the cycle by pressing against the walls at the end of the openings. If the pressure is relaxed the counting stops and the device alarms. When in this position, the back and front of each hand is in close proximity to a separate proportional counter. Thus, it is impossible for the system to fail to detect a 0.001 microcurie beta source on a ring face directed to either the palm or dorsal surface of the hand. Accordingly, the maximum time period the source could be available to the ring would be based upon the maximum amount of time the individual was actually in the work area. As described in Section III.A, the subject individual was involved in two work activities during the period in question. He performed work on the Unit 3 reactor coolant pumps (RCP) and the Units 2/3 crud tank pump (CTP). Based on interviews with the worker and the Health Physics Technicians who covered the jobs, the specific work scope for the individual was determined. For the RCP work, the individual did not actually enter the pump shrouds (see Figure III-1), but rather remained on the platform nearby. He assisted in the movement of the extracted seal and briefly touched the outer surface of the plastic bag which had been placed over the seals. For the CTP work he helped disassemble, clean and reassemble the pump. In order to determine the minimum source activity necessary to deliver p 511.99 rad, the maximum possible exposure times were determined as v follows.

IV-8 The longest entry to the radiologically controlled area made by the O individual for the RCP work was from 0828 to 1421 (Entry 1) on 10/06/86. b Because of the time consumed, in changing to modesty garmets and in donning and doffing protective clothing, the actual time spent in the work area during this entry was approximately 4.9 hours. The longest entry to the radiologically controlled area for the CTP work was from 0812 to 1107 (Entry 4) on 10/20/86. Due to the reasons cited above, the actual time spent in the CTP work area during this entry was approximately 1.9 hours. These time periods are based upon computer entry records (IRAD/0 RAD data) and interviews with the worker. Copies of the IRAD/0 RAD and interviews are included in Attachments III-14 and III-15. The conclusion is, therefore, that the source must have been i capable of delivering at least 104 rad /hr to the TLD if the exposure occurred during the RCP work, or 269 rad /hr if the exposure occurred during the CTP work. The maximum exposure rate would occur on contact with the source. Therefore the minimum particle activity to produce 104 rad /hr or 269 rad /hr (as applicable) would be with the source as close as possible to the TLD. However, since it has been established that the source was not in contact with the individual or his ring prior to the individual's entry into the work area, and he donned protective clothing prior to entering the work area, the closest the source could be to the TLD would be determined by the intervening thickness of the protective clothing directly over the TLD. This would place the source on the outside of the second plastic glove set worn by the individual. It should be noted that the Health Physics Technician covering the CTP work required the individuals performing that job to change their gloves l following disassembly and cleaning of the pump (see Attachment III-12). Therefore, the time period the particle could have been on the outer glove of the individual during this job had to be less than the 1.9 hour estimate because no single outer pair of plastic gloves was worn this long. Nevertheless, in order to consider the worst possible case, the t calculation of the minimum activity source for CTP work was based on 1.9 hours. Based on the maximum time periods established above, the type (beta /ganma) and the energy of the radiation emitted from a fuel fragment or cobalt 60 particle, and the location of the source relative to the TLD, the minimum activity particle required to produce the 511.99 rad exposure is presented in Table IV-1. Table IV-1 Minimum Activities of Specified Particles to Produce 511.99 rad For the RCP work: 51 microcurie fuel fragment or l 860 microcurie Co-60 particle For the CTP work: 132 microcurie fuel fragment or O 2,218 microcurie Co-60 particle _-.______.-_.______--____.,__,_-._,_..._,._,m.,-__,,._,-

IV-9 The calculation methodology for these activities is provided in Attachment IV-4. Since the exposure rate drops rapidly at increased distances away from the source and because of the limited view the chest and left hand TLDs could have had of the source (which is assumed to be located directly over the right hand TLD) the exposure to the chest and left hand TLD would be minimal. O k O

IV-10 IV.2.B. RCP SEAL WORK With a knowledge of the smallest possible activity: fuel fragment (51 microcuries) or cobalt 60 particle (860 microCuries) necessary to produce a 511.99 rad dose during RCP seal work, we can now examine survey data and techniques to ascertain whether it is reasonable to assume that a particle of such activity would have been detected in the RCP work area. As noted previously, the individual assisted in the removal of the RCP, P003 seal from the platform outside the RCP shroud. When the seal was lifted, it was enclosed in a large plastic bag by the workers within the shroud. During the process of removing the bagged seal from the shroud and lowering it to its transport container, the individual briefly touched the outsih of the plastic bag as he assisted in the moving operations. After the removal operation, the bagged P003 seal remained sealed within its transport container until February 24, 1987. On that date the bagged seal was lifted out and the entire outer surface of the plastic bag was carefully surveyed for fuel fragments, radioactive particles and other contamination. The bag was found to be free of fuel fragments and other radioactive particles. One ruthenium particle, with a decay (to October 15,1986) corrected activity of 0.7 microcuries was found on the surface of the P003 seal. Smearable contamination levels on the outside of the bag were found to be 20-50,000 dpm/100 cm beta / gamma. The survey results 2 provided a basis for concluding that it is very unlikely that the individual could have picked up a 51 microcurie radioactive prfticle from this evolution. See Attachment III-7. The radiation and contamination surveys performed for the RCP work during the month of October 1986, were reviewed. Records of the surveys are attached as Attachments III-2, III-3, III-5 and III-6. A discussion of survey effectiveness for detecting fuel fragments is included as Attachment IV-5. A discussion of survey effectiveness for cobalt 60 is included as Attachment IV-6. The average gamma radiation levels on the platform, where the individual spent the majority of the time were around 30 mR/hr. These measuremeits are based on closed window Eberline R02 readings at approximstely 3 ft. above the platform. The maximum beta radiation level for the work, as measured inside the RCP pump shrouds, was 6 rad /hr. These readings are based on open-minus-closed window R02 readings (corrected for bota response) measured in contact with surfaces. The maximum gamma radiation level inside the shroud (at 3 ft. above the floor) was 20 mR/hr. By assuming that this beta radiation level resulted solely from a fuel fragment it can be concluded that the maximum activity fuel fragment associated with the RCP seal work would be 13 microCuries and the maximum activity fuel fragment associated with seal P003 was 0.9 microcuries (see AttachmentIV-5). If the beta radiation levels in the shroud are assumed due solely to a cobalt 60 particle then the maximum cobalt 60 particle associated with contamination from the RCP work would be 18 microcuries (see Attachment IV-6). Based on the preceding it appears very unlikely that a particle sufficiently active to produce the reported dose would have gone unnoticed.

IV-11 IV.2.C. CRUD TANK PUMP WORK A knowledge of the smallest possible activity fuel fragment (132 microcuries) or cobalt 60 particle (2218 microcuries) required to produce a 511.99 rad dose during CTR work provides a basis for examining the CTP survey information to determine whether it is reasonable to assume that a particle of such activity would have been detected in the CTP work area. The radiation and contamination surveys performed for the CTP work between October 19 and 21, 1986 were reviewed. Survey information is included in Attachments III-10, III-11 and III-12. Evaluations of survey capabilities are attached as Attachments III-13 and IV-6. These surveys were conducted with the same techniques as the surveys for the RCP work. As discussed in a previous section, a Health Physics Technician provided constant coverage of the work on the Crud Tank Pump on October 20 (Entry 4 and Entry 5), and on October 21 (Entry 6). The Technician provided a statement covering the extent of his surveys, which is included in Attachment III-12. A review of the statement, and the instrumentation used, was conducted by a Health Physics Engineer and is included as Attachment III-13. The average gamma radiation level in the area was 10-20 mR/hr. The maximum beta radiation level noted was 1000 mrad /hr. By assuming the beta radiation levels resulted solely from a fuel fragment it was concluded that the maximum activity fuel fragment associated with the p pump and component contamination would be 2.5 microcuries (see Attachment V III-13). If the beta radiation levels associated with the contamination from the CTP work are assumed due solely to a cobalt 60 particle, then the maximum cobalt 60 particle associated with contamination from the CTP work would be approximately 3 microcuries (see Attachment IV-6). Based on the preceding it appears very unlikely that a particle sufficiently active to produce the reported dose would have gone unnoticed. O_

IV-12 IV.2.0. STATISTICAL ANALYSIS OF RADI0 ACTIVE PARTICLE DISTRIBUTIONS I 1 V In order to fully understand how to control radioactive particles at San Onofre, an aggressive program of particle collection, measurement, and statistical analysis was undertaken, beginning at the end of 1985. As a result, data are now available which enable description of the activity distribution of particles, as well as a limited description of their relative distribution throughout the plant. A total of 312 particles have been identified in the Units 2/3 Radwaste Building and Unit 3 containment by this census through 2-8-87. The results of a statistical analysis of these data indicate that the maximum probabilities of observing particles in the individual's work locations of the minimum magnitudes specified in Table IV-1 are quite small. Of the 312 particles studied, the highest activity fuel fragment actually identified outside of the Unit 3 Fuel Handling Building was 8.7 microCuries. -See page 11 of Attachment IV-7 for the fuel fragment distribution as a function of activity. It was in the Unit 3 Fuel Handling Buf1 ding, in :onnection with fuel reconstitution activities in 1985, that the fuel fragment problem was first observed. A major fuel fragment decontamination campaign was undertaken in that area at that time. Access to the Unit 3 Fuel Handling Building has been closely controlled since that time and neither the individual who wore ring 80365, nor the ring itself had been in the Fuel Handling Building during the period in question. N) The distribution of cobalt 60 particles identified includes 34 particles, 28 of which have been identified in Unit 3 since January 2,1987. See page 10 of Attachment IV-7 for details. The highest activity particle found was 70 microcuries. A detailed statistical analysis was concluded (see Attachment IV-7). The maximum probabilities of observing particles of the minimum magnitudes specified in Table IV-1 were calculated using Tchebysheffs Theorem and are displayed in Table IV-2. l l O

' IV-13 Table IV-2 - /7 Maximum Probability of Occurrence particles of Specified V-Isotopes and Activities Based on Particles Observed Type of Particle Probability fuel fragment for the RCP work 0.00009 cobalt 60 particle for the RCP work 0.0032 fuel fragment for the CTP work 0.000014 cobalt 60 particle for the CTP work 0.00047 When these minimum magnitude particle activities are analyzed, as shown in Attachment IV-7, they are seen to be outliers from the distribution of particles found at San Onofre. Therefore, it is highly unlikely that such sources could have been present in the work areas. Surveys conducted of the work areas prior to, and during, the job evolutions confirm that no such fuel fragment sources were identified. Since even the minimum size source required to produce the 511.99 rad exposure was not available within the distribution of fuel fragments and cobalt 60 particles found in accessible work places at San Onofre, it is concluded that the TLD was not exposed to a source during any of the worker's job sequences within the radiologically controlled area. p Nctwithstanding this fact, enhancements have been made to the San Onofre t. radioactive particle control program to take into account the remote possibility that particles of activity sufficient to cause the reported exposure might exist at some locations in the plant. i /9 V l l i i

IV-14 IV.3 WAS THE EXPOSURE REPORT VALID? O v Since it appears that no radiation source capable of delivering the reported dose was available, and that the ring was not exposed while not in use, the alternative that the exposure report itself may not have been valid requires exploration. To examine the validity of the exposure report three questions need to be addressed. They are: A. Could the report be the result of a processing error or anomaly? I B. Could the report be linked to any weaknesses in the vendor's processing? C. Are the available data supportive of a valid exposure report? IV.3.A. PROCESSING ERROR OR AN0MALY Arrangements were made to have Dr. Phillip Plato of the University of Michigan assist in investigating the subject exposure report. Dr. Plato visited the vendor's processing facility on 2 occasions to observe and evaluate the vendor's system for processing extremity dosimeters. Dr. Plato concluded from his examinations of the vendor's processes that no specific mode of processing error was indicated. For instance, the vendor's annealing, alcohol bath, and ring loading procedures made it unlikely that ring 80365 was not properly " zeroed" prior to shipment to San Onofre. Observations of the chip unloading and handling processes G indicated that it was improbable that the chip reported as having come O from ring 80365 was actually inadvertently taken from another customer's shipment or from a vendor's test process. No indication of vendor tampering was evident either. While no specific processing error was indicated, Dr. Plato, a recognized expert in the field of personnel radiation dosimetry, made significant conclusions regarding the quality of work and attention to detail observed at the vendor facility. Observations regarding the lack of glow curve records, chip histories, and procedures regarding the preservation of high dose chips were made. Significantly, the vendor failed to follow internal procedures by making immediate notification of a high dose reading and performing the required read down procedure while processing ring 80365. O

IV-15 IV.3.B. VENDOR WEAKNESSES !'v Several weaknesses in the dosimetry vendor's processes have been identified and discussed. While all of them certainly have served to make the validation of the exposure report more difficult, certain of them can be assumed to be potential causes of an erroneous exposure report. One weakness is the vendor's failure to perform the normally employed read down test. This test is an important procedure for determining whether the light output recorded is due, not to the TLD luminescence, but to some foreign material combusting or luminescing during the heating cycle. To attempt to reproduce the reported readings by chemical contamination, tests were performed using dosimeters identical to ring 80365. Based on interviews with the worker, several chemicals were identified which could have contacted the workers ring had the sonically welded cover not been intact. These chemicals included EMC, inhibisol, electrosol, rapid tap, aerokriol and ifquid soap. To determine if any of these chemicals could have caused the 511.99 rad reading several tests were conducted. One test dosimeter was exposed to each of these chemicals. Prior to being exposed, each test dosimeter had its label removed and a small opening was made in the clear plastic window with an exacto knife (see description of ring in Section III). Each chemical was then applied to the ring 2 or 3 times. The label then was then replaced. As shown in s) Table IV-3 all tests resulted in values below the minimum reportable level. Table IV-3 Non-Radioactive Agents Test Result EMC M* Inhibisol M Electrosoly M Rapid Tap M Aerokriol M Liquid Soap M Saline Solution 50 mrem Fluorescent Light M Welding Arc (label on) M Welding Arc (label off) M WedlingArc(windowoff) M Radio frequency M w

• Below minimum reportable (10 mrem gamma, 40 mrem beta).

s

IV-16 Additionally, since the worker had reported that his hands were always O' soaked with sweat while working, a saline solution was also tested. A ring, with the label removed and an opening made in the window as described above, was immersed in a saline solution for 2 hours at 110 cegrees F inside a chemistry lab hood. After the 2 hour immersion period the label was replaced. As shown in Table IV-3 the test results indicated 50 mrem. However, this non-zero result was probably due to high radiation background in the chemistry hood. O l l O

^ r IV-17 IV.3.C. REPORTED OUTPUT AND RESIDUAL gy V As previously noted, actual data available on ring TLD 80365 was limited to the light output (expressed in nanoCoulombs) from the initial reading and one additional reading. The reasonableness and reproducibility of the second reading, frequently referred to in this report as the " residual", was carefully reviewed. Since the initial reported 5.12E6 nanoCoulomb output and the second 5.93E5 nanoCoulomb output form the only bases for the vendor's assertion that the observed results were due to radiation exposure, it is essential that those values be reasonable, and reproducible. The reported 11.48% residual reading was found to be far outside the range of values found by other experts in the field of personnel radiation dosimetry. It also exceeded, by a wide margin, the values observed by the vendor during a calendar quarter selected for examination. (See the section entitled " Variations Between Chips" and Table IV-7 later in this section for details.) Furthermore, the reported residual was demonstrated to be far in excess of the values produced when the vendor processed a large number of ring TLDs exposed to doses from several radiation types which bracketed 500 rad. Figure IV-1 presents a compilation of 172 data points produced when TLD rings were exposed to gamma, beta, neutron and irradiated fuel fragment (listed in the legend as " Fleas") radiation doses between 10 and 10,000 rad. With the exception of the points marked " Consultants" all ring TLD chips were evaluated by the vendor. The " Consultants" data points above 10,000 rad are discussed in a subsequent section entitled "LiF Total Dose Dependence." As can be observed from Figure IV-1, results of extensive tests performed by SCE and independent experts yield consistent, reasonable, reproducible data that affirm that exposure of LIF TLD-100 elements to doses of radiation in the range of 10 to 10,000 rad produce residuals of under 2%. This conclusion is further developed in Attachment IV-7. Attachment IV-7 presents a statistical analysis which employs three established tests to determine the probability that the reported 11.48% residual is a member of the data set generated from the tests cited here. As shown, the 11.48% reported residual is an outlier from these data. According to Tchebysheff's Theorem, the maximum possible probability of observing an 11.48% residual under the specified conditions is 0.00044. On the basis of this evidence it is concluded that the reported exposure is unreasonable, unreproducible, and invalid. As praviously noted, Dr. Phillip Plato was asked to review the vendor's process and to provide an evaluation regarding the validity of the high exposure report. Dr. Plato submitted an initial report which provided the basis for much of the information in Section III.B of this document. He submitted a second report, dated January 7, 1986 which provided information that was used in the preparation of Section IV.D of this document. v

1 IV-18 y Dr. Plato provided a third report to San Onofre on February 20, 1987. A O copy of this report is included as Attachment IV-9. The bulk of this O report consists of information on test exposures performed at the request-of SCE and tables of data generated from these tests. In this report Dr. Plato also noted that during his first visit to the. vendor on December 18, 1986, he was told that a residual of 11.5% was normal for LiF elements processed with the laser TLD reader. He was shown a dose-response graph that supposedly indicated about a 10% residual from 10 rad to 1000 rad, but he was not permitted'to have a copy of the graph. He noted that his first report to San'0ncfre reflected the statement by the vendor that an 11.5% residual was within the normal range. In this regard, the report states: "This assumption is discussed on page 11 of my report (of December 31,1986), and it is the basis of my second conclusion on page 13. '2. It is likely that the large response for ring badge no. 80365 was caused by ionizing radiation. This conclusion is based primarily on the 11.5% residual observed when the element was read the second tire.' " Discussions with Tommy Johnson of the Naval Research Laboratory and q Nels Johnson of Eberline Instrument Company, both of whom are V involved with radiation dosimetry using LiF, did not substantiate (the vendor's) contention that 11.5% is a normal residual. The general opinion is that 0.5% to 1.0% is the normal range, and 11.5% is completely abnormal." In order to investigate residual responses, extensive additional tests i were undertaken. The results of these tests are presented in the February 20, 1987, Plato report. Based on this information, Dr. Plato was able to draw final conclusions which are quoted below. "There are only two facts that are known about ring badge no. 80365. First, the initial response of the element from this ring badge was 5,120,000 nC. Second, the next reading of this element following a calibration irradiation to 350 mrad from Sr/Y-90 showed a residual of 593,300 nC, about 11.5% of the initial response. Since(the vendor) discarded the element after the second reading, and since (the vendor) generates no specific data on loose elements, we have no other clues to interpret the initial response exceot for the (un)usually large residual. O

~_ 3r f +., ) IV--14e ~ s Ele'!nr tv-1 .x rtons.2 TLD-100 Chip % Residual as a Fhnetion of Dose l Laserr and Gas-read Data 16 - l A li-Legend x. ) @ Rang 80365 x.. + Cs-13'1 12-x sr/Y-40

• E.1/Rh Particles 0

l T Other l 10- ^ w a Cf-212 ~ g a .e.a.,.e.. '.U + X-rays O' r g x Thalium-2C4 (g

• Other M

m Consultants M 6_ a Unamed Puse a Wed PuBe t 4- ^ M w 3. 2- +, x x x* xf+%* x+ Y a ut & o "a_*Xt [***M **$*.-,."....c,----*

• • A

+,., # 'Da a ,,....m 0 10 10C 1000 10000 100000 ~ Dose in Rads Green symbols denote I.aser-read data All Data. Except Consultants Read by Jendot-Blue symbols denote Gas-read data m 'w

P e

.,,_g.____ y ,7

-= IV-19 "I can identify three ways in which an unusually large residual can (} be produced. First, the element received a very large dose of G ionizing radiation. Based on the cobalt-60 irradiations done for Eberline (80,000 rad minimum to cause a residual around 11.5%), and based on a typical conversion factor for gamma rays (10 nC/ rad), an element would have to show an initial response of about 800,000,000 nC to produce a residual of about 11.5%. However, the element from ring badge no. 80365 showed an initial response of only about 5,000,000 nC. This initial response appears to be too small to cause an 11.5% residual. Therefore, based on the data generated at (the vendor's facility) during January and February, and based on the data provided by Eberline, I conclude that the 5,120,000 nC initial response of ring badge no. 80365 was not caused by ionizing radiation. "A second way in which a large residual can be produced is if the TLD reader malfunctions during the initial reading of an element and does not empty all of the electron traps (i.e., incomplete heating). The second reading of the element would reflect residual plus a portion of what should have been the initial response of the element. If this is the cause of the large residual for ring badge no. 80365, then the malfunction occurred coincidentally when a high-dose element was being read. Since laser TLD reader was used to process 646 other ring badges from SONGS on November 10, 1986 without a similar malfunction, I find this coincidence too much to accept. I doubt that a malfunction of the laser TLD reader caused the 11.5% residual. "A third way in which a large residual can be produced is if the element were contaminated with a combustible material. This would cause a large initial response, and it could cause a large residual response if the contaminar.t were still present after the initial heating. Subsequent readings might have suggested the presence of a contaminant, and visual inspection fo the element might have com %2d the presence of a contaminant. Unfortunately,(the vendor;. discarded the element after the second reading. I believe the presence of a contaminant is the most reasonable explanation of the large initial and residual responses of ring badge no. 80365." O

.IV-20 IV.D. OTHER TESTS .O-A series of tests were performed in an effort to identify an effect which. could have produced the observed results. Harshaw Lithium Fluoride TLD-100. chips and rings were exposed and read under a variety of conditions. The tests and results described.in this subsection include: 1. TLD Chip Overheating t 2. Laser Heated vs. Gas Heated Reader 3. -Reader Calibration Variation 4. LiF Dose Rate Dependence 5. LiF Total Dose Dependence 6. Sensitivity Variation Between Chips 7. Source Size Effects j 8. Radiation Type Dependence i As shown in the following discussion of these tests, no radiation or - other effects, which could produce the reported exposure, were identified. TLD CHIP OVERHEATING-At the request of Dr. Phil Plato, Mr. Nels Johnson of Eberline Corporation performed a set of experiments to determine the effects of greatly a overheating TLD-100 phosphors. Forty chips were irradiated to 10- rads. 20 of these chips were then heated in an oven at 600'C for 35 seconds. l (The normal heat cycle for the gas reader used by the vendor is 250'C for 10 seconds.) LiF has a melting point of 1200*C, but at 400*C it starts to incandensce. This incandescence would cause a very high light output reading. Tnese chips were subsequently cooled and then read out twice, l and produced a zero response each time. The other 20 chips were first read out prior to oven heating. They were then heated, cooled and read. All produced zero response. Therefore it was concluded that, though overheating of a chip may cause an initial high light output due to incandescence, it will not cause a high e residual. This conclusion, combined with the logic that two consecutive reader malfunctions'in the heating cycle would have to occur to cause the l reported readirgs by incandescence, make overheating an unlikely cause j-for the reported effect. i LASER HEATED vs. GAS HEATED READER The introduction of laser heating in thermoluminescent dosimetry is new with little operational history. Data were therefore produced to examine i-the potential effect of laser heating on initial and residual readouts of TLD-100s. Several rings were irradiated to a range of doses and were then processed by the vendor on a gas heated reader. The process was repeated but this time the vendor used the same laser heated reader used i to read ring 80365. Specific processing instructions were provided by SCE and Dr. Plato obst.rved the processing of these rings. The results of these tests are tabulated in Table IV-4. The coefficients of variation l between the residuals observed on the two readers and between chips in the same dose range read on the laser reader only, were not significant. l-

IV-21 Table IV-4 .,e s U SCE Residual Tests Gas vs. Laser Reads Dose (rad) Gas Laser Total a b c a b c a b c 10-99 10 0.48 57 36 0.18 99 45 0.24 96 100-299 32 0.39. 65 32 0.39 65 300-499 22 0.86 55 22 0.86 55 500-699 11 0.53 134 11 0.53 134 700-999 19 0.51 90 19 0.51 90 1000-2999 21 0.38 133 21 0.38 133 l 3000-6999 14 0.59 102 14 0.59 102 > 7000 6 0.58 41 6 0.58 41 O a = number of data points b = average % residual c = % coefficient of variation of the % residual (= standard deviation + mean x 100) READER CALIBRATION VARIATIONS Some experts consulted suggested that residuals at high doses might be sensitive to the calibration of the TLD reader. To test this possibility, several batches of irradiated rings were sent to the vendor for processing over a two month period beginning in mid-December,1986. The vendor performs reader calibrations at least monthly. The results of these tests are included in Table IV-5. Significant variation was noted in the residual values between ring batches. Nevertheless, no residual values above 2% were reported. .p-~\\ 's,)

Table IV-5 SCE Residual Tests Comparison of Each Processino Batch i Dose (Rads) T 7005 T 7006A T 7013D T 7022 T 7023 1 i 1 a 1 b I c a i b 1 c i a i b i c a i b I c a i b I c I l i I i - 1-i i 1 i i 1 1 I i 10-99 1 11 1 0.281 77 1 31 0.351 35 1 -- 1 - 1 -- 1 1 -- 1 -- 1 1 I I I I I I I i 1-1 I I I I I I i i i 100-299-l 11 1 0.611 32 1 -- I 1 -- 1 5 1 0.381 29 I 5 1 0.551 25 1 -- I I -- 1 I I I I I I I I I I I I I I I I I i 300-499 I 9 1 0.758 34 1 3 1 1.06l 22 1 - 1 I -I I 1 51 1.431 30 I I I I I I I I I I I I l-1 I I I I I 500-699 I 1 -- 1 I 3 1 1.611 16 1 I - 1 1 1 I I I - l l 1 1 I I I I I I I I I I l I I i 1 700-999 1 6 1 0.851 52 I -- 1 1 1 1 -- I 1 1 I 1 1 - I 1 I I I I I I I I I I i i 1 1 1 1 I i 1000-2999 1 2 1 0.821 25 1 3 1 1.311 13 1 - 1 I 1 I I I - 1 1 I i 1 1 1 1 I I I I I i 1 1 1 1 1 1 3000-6999 I 1 1 -- 1 31 1.621 23 1 I I I 1 1 -- 1 - I 1 I I I I I I I I i 1 1 1-1 I I' 1 I i 2 7000 1 1 1 -- 1 -- 1 I -- 1 I 1 1 1 I 1 - 1 1 I I I I I I I I i 1 1 I I I I i 1 1 Batch I T 7029 T 7028 U MICH T 7041 FUEL FRAGMENTS E 0115A i 1 Dose (Rads) I a i b 1 c a i b I e a i b i e a i b 1 e a i b i c a i b 1 c 1 1 I I I I I i 1 1 1 I I i . 10 1 0.481 57 1 1 I I I 10-99 1 -- I - I -- I -- I - I 18 I 0.081 103 1 I I 1 4 1 0.211 65 1 1 1 1 I I I I I I I 1 1 1 1 1 i l I i I i 100-299 1 -- 1 1 -- I -- 1 I l 9 I O.111 100 I - I -- 1 4 1 0.221 55 1 I 1 1 I I I I I I I I i 1 I I I i 1 1 I I I i 1 300-499 I 1 1 -- 1 -- 1 I I - 1 -- 1 1 I 1 5 1 0.421 80 1 1 - 1 l l l I I i 1 1 1 1 1 1 1 1 I I-l 1 1 I I I 500-699 I -- I - 1 1 I 1 I 51 0.031 99 l -- 1 1 -- I 3 1 0.291 26 1 1 - I -I I I I I '1 I I i 1 1 I I I I I I I I I I I 700-999 I -- I - I 1 5 1 0.251 9I 5 1 0.131 99 I -- I 1 -- 1 2 1 0.611 32 1 -- I 1 1 I I I I i 1 I I I I I I I I I I I I I I i 1000-2999 I - I I -- 1 I l 13 1 0.061 73 6 1 ' I 1 3 I 0.351-38 1 1 I 1 I I I i 1 1 I i i 1-1 I I I I I I I I i 1 3000-6999 I 5 1 0.421 23 1 1 I -- 1 I 1 -- 1 6 1 0.221 87 1 -- I -- I 1 -- I I 1 I i 1 I I I I I i 1. 1 I I I I I I I I I I 2 7000 1 1 - 1 1 4 1 0.501 31 1 I - 1 I -- 1 I -- l 2 1 0.751 49 I 1 1 1 i i i i I I I I I I I I I I-1 I I I i 1 a = number or data points b = average % residual c = % coerricient or variation of the % residual (= standard deviation i mean x 100) IV-22

m IV-23 LiF DOSE RATE DEPENDENCE- - i No indication was.found, either via literature search or conversations with experts, that high residuals could be produced by dose rate . effects. In the interest of thoroughness, however, tests were-performed..Several TLD-100 rings were irradiated with cesium 137~at dose rates between 1 rad // hour and 3000 rad / hour._ No evidence of dose rate i - dependence was found, with the residual readings all falling below 2%. A second-set of 15 rings was exposed to cesium 137 doses of 500 rad at rates of 10, 100, and 810 rad / hour. No dose rate effect was observed and no residual above 0.6% was reported. To determine if a small, high activity particle located directly over a LiF chip could produce high residuals due to saturation of a very.small - area of the phosphor, several tests were conducted with fuel fragments. . Numerous exposures, over a wide range of doses, failed to yield residuals above 1% as reported by the vendor (see the column in Table IV-5 labeled " Fuel Fragments"). LiF TOTAL DOSE DEPENDENCE i .Several personnel radiation dosimetry professionals responded to inquiries by stating that residuals above 2% were only observed in very high dose ranges. TLD theory maintains that high residual readings can be obtained when the higher energy traps in the thermoluminescent al material become filled after exposure to extremely high doses. Electrons promoted to these levels-'during irradiation may then drop to lower energy levels during the first read. They will then produce luminescence on the second read, yielding high residual values. Nels Johnson of Eberline provided data on residuals observed in chips exposed to high doses. This data was obtained recently when Eberline was i- - asked to do an experiment with TLD-100 chips irradiated to cobalt 60 doses. ranging from 10,000 to 100,000 rad. The results:are displayed in t. Table IV-6. By interpolation, it can be determined that a residual of (. =11% would be expected from a dose of at least 65,000 rad. No ~ plausible explanation is available for how ring 80365 could have received a dose which would produce this effect and still register only 512 rad -upon initial readout. Additionally, prompt and noticeable biological effects would be expected if an individual's extremity was exposed to 65,000 rad. As detailed in Section II, no medical evidence of excessive exposure was found. [ o .n-.- .-.~- ~ ,.a w. ..,,=-------,-----.--,--r-, ,,n-n,-a- ---ww mrn -r.,m s,

o IV-24 [) Table IV-6 x) High Dose Residuals Cobalt 60 Irradiations Dose ~(rad) % Residual 10,000 0.4 20,000 3.5 40,000 6.8 80,000 13.9 100,000 14.3 _J VARIATIONS BETWEEN CHIPS Lithium Fluoride,TLD-100 chips are, of course, subject to physical variations. Whether or not these variations could lead to substantial t variances in performance (e.g., residuals) was examined, k.)S In response to a request from San Onofre, the vendor searched the records of all exposure evaluations done during the fourth quarter of 1986. In excess of 220,000 chips had been evaluated. More than 70,000 had been evaluated with a laser reader and about 180,000 with a gas heating reader. Excluding the 511.99 rad reported value and the series of test exposures-reported for San Onofre, the vendor found 37 reports of 10 rad or more. Four of these were the result of laser reader evaluation. The remaining 33 chips had been evaluated on a hot gas reader. The results are displayed in Table IV-7. No residuals in excess of 0.5% were reported. Based on these findings and those presented in Tables IV-4 and IV-5, it is unlikely that variations among chips could account for the 11.48% residual. 1" \\ t

r IV-25 Table IV-7 Vendor Data Search, last Quarter 1986 Laser Read Chips First Read Second Read Dose *(rads) (nanoCoulombs) (nanoCoulombs) Residual 160 2250000 9400 0.42 160 2510000 12200 0.49 160 2200000 7100 0.32 20 316600 1025 0.32 Hot Gas Heater Chips over 10 319300 57 0.02 over 10 267700 273 0.10 over 10 277300 449 0.16 over 10 224400 53 0.02 over 10 132500 48 0.04 over 10 128200 63 0.05 over 10 130100 79 0.06 over 10 153900 48 0.03 f ~x over 10 109500 84 0.08 ',)- over 10 140300 58 0.04 ss over 10 113900 54 0.05 over 10 106200 75 0.07 over 10 124500 101 0.08 over 10 137300 87 0.06 over 10 107000 76 0.07 over 10 145000 72 0.05 over 10 116100 93 0.08 over 10 208500 111 0.05 over 10 130400 112 ~0.09 over 10 36600 55 0.15 over 10 214100 139 .0.06 over 10 127400 92 0.07 over 10 36900 46 0.12 over 10 182300 101 0.06 over 10 139500 83 0.06 over 10 53000 33 0.06 over 10 216200 297 0.14 over 10 131900 105 0.08 over 10 34600 49 0.14 over 10 112600 72 0.06 over 10 159500 75 0.05 over 10 122200 58 0.05 over 10 115200 64 0.06 ()

• The 160 rad dose was applied by a testing laboratory as part of a NVLAP qualification program. The 20 rad dose was reported by the vendor. All other doses were reported as being between 10 and 20 rad.

IV-2$ RADIATION TYPE DEPENDENCE nI'] Hundreds of irradiations were performed by SCE and its consultants to determine if high residuals could be produced by exposure to a particular type, or energy, of radiation. Both ionizing and_non-ionizing radiation exposure tests were conducted. Except where stated otherwise, such as in Table IV-6, all test results were provided by the vendor. Despite repeated efforts, no high residuals were reported other than those found in the very high dose ranges reported in Table IV-6. The initial SCE experiments involved the exposure of the TLD rings to strontium yttrium 90 and cesium 137 sources at various exposure angles and with different shielding thicknesses. Varying doses were used to test for linearity of response in the high dose ranges. In addition, one ring was cycled 3 times through an X-Ray baggage inspection machine and 2 rings were opened and placed on a sealed alpha radiation source. The results of these initial irradiations are presented on Table IV-8. No residuals over 0.2% were reported for these initial irradiation experiments. A second set of test were performed under carefully controlled conditions. Forty-eight elements were given varying doses of cesium 137, MFI X-Rays, strontium yttrium 90, ruthenium 106, thalium 204, and fuel fragment radiations. The exposed rings were then processed by the vendor using a laser heated reader while under the observation of Dr. Plato. Dr. Plato provided a summary of his observations in a report to SCE dated January 7,1987. Dr. Plato observed that the 48 rings submitted by San Onofre were processed in generally n the same manner as had been described to him by the-vendor representative V during his earlier visit. Exceptions noted included an increased number of workers involved with the processing of the San Onofre rings (due to Dr. Plato's presence) and the performance of some special processing steps specially requested by SCE. Those steps included the addition of two extra quality control elements to the batch and a total of four reads per element to accumulate precise residual data. Interestingly, Dr. Plato noted that broken TLD chips (a reportedly common situation) were not rejected, but were i processed by reading the largest portion and discarding the smaller. Review of the data reported as a result of this experiment (shown in Table IV-9) l showed no relationship between residual, radiation type, or Linear Energy l Transfer (LET). Average residuals for each radiation type did not exceed 1%. Additional residual data were supplied by Dr. John Frazier. Irradiations were l performed in 1979 by exposing Harshaw LiF TLD-100 ribbons to 100 rad from a cobalt 60 source. The gas heated reader results yielded residuals in the 0.5% to 1% range (see Attachment IV-8). l During January and February,1987, Dr. Plato, at the request of SCE, irradiated i a number of TLD rings with various radiation sources. Each ring contained a l LiF TLD element, and was irradiated on a tissue equivalent phantom. The i radiation sources used included cesium 137, MFI x-ray, thallium 204, l californium 252, and a 2 MW research reactor. Total doses reported by the vendor after processing were from 100 to 1000 rad, bracketing the 512 rem reported value. The rings were processed using a laser heated reader and were read a second time to determine the residual. Dr. Plato describes the method and results of these experiments in a report to SCE dated February 20, 1987. (o) The average residual for the 87 irradiated elements was 0.23%. The largest residuals reported were 1.33% and 2.67%, both as a result of irradiation with 3.5 rad by neutrons plus gamma rays from californium 252 moderated with heavy water. l

'IV-27 Table IV-8 Initial Experiments Calculated Reported Source Dose (rad) Dose (rad Notes Pu-239 (alpha) 8 0.156 (1) Pu-239 (alpha) 8 0.152 (1) X-ray 0 M. (2) Sr/Y-90 1624.5 180.0 (1)(3)(4) 2948.2 300.0 (1)(3)(5) 2948.2 190.0 (1)(3)(6) 300.0 3.560 (1)(3)(7) 1.0 0.030 (1)(3) 1.0 0.100 (1)(3) 1.0 M (1)(2)(3) 10.0 0.960 (1)(3) 10.0 0.590 (1)(3) 10.0 0.520 (1)(3) 500.0 4.170 (1)(3) 500.0 90.0 (1)(3) 500.0 42.310 (1)(3) Cs-137 0.1 0.130 0.1 0.140 i 0.1 0.130 \\ 1.0 0.900 1.0 0.990 1.0 0.980 10.0 10.120 10.0 10.670 10.0 11.190 500.0 570.0 i. 500.0 495.0 500.0 600.0 1 (1) Dose calculation highly questionable due to geometry factors. l (2) Below minimum reportable. (3) Dose calculated for unshielded source. l (4) Shielded by one cotton liner. (5) Shielded by cotton liner, rubber glove. (6) Shielded by cotton liner, 2 rubber gloves. l (7) Side shot. i I L

4 IV-28 j-)/.. Table IV-9 SCE Residual Tests Source Comparisons -Dose (Rads) Neutron Beta Gamma a b c a b c a b c 10-99 16 0.34 86 21 0.16 92 9 0.26 94 100-299 3 0.23. 47 7 0.45 26 22' O.39 68 i 300-499 11 0.70 56 11 1.05 46-500-699 6 0.95 78 5 0.03 99 700-999 3 0.19 67 3 0.35 38 13 0.49 92 1000-2999 8 0.08 51 8 0.89 47 5 0.02 37 l 3000-6999 3 1.62 23 11 0.31L 59 () a = number of data points b = average % residual c = % coefficient of variation of the % residual (= standard deviation + mean x 100) t l i { ( L 1 e

m V-1 V. CONCLUSION Based on the preceding information,.it is concluded that the reported exposure is invalid and that the individual did not receive an exposure in excess of that indicated for the other hand. The conclusion rests on three basic findings, namely; The effect (11.48% residual) cited by the vendor as the basis for asserting validity could not be reproduced. In a test. set of.172 TLD rings exposed to beta, gamma, neutron and irradiated fuel. fragment radiation, the doses delivered ranged from 10 rads to 10,000 rads (Figure IV-1). The highest residual found was 2%. The vendor examined the residuals from all TLD chips exposed to over 10 rad among the more than 200,000 TLD evaluations done during last, quarter of 1986. The highest residual-. observed was 0.32%. Data from a test performed by another vendor indicates that residuals in excess of 2% are not observed until the dose delivered exceeds 10,000 rad. According to: that vendor's data, a residual of 11.48% corresponds to a dose of at. least 65,000 rad. Such a dose would have produced prompt, obvious and i lasting physical effects. None were. observed. The minimum activities of particles required to produce such a dose.are: 6,475 microCuries of f irradiated fuel or 109,200 microCuries of cobalt 60. -Statistical analysis of all radioactive particles catalogued (312 irradiated fuel fragments and 34 cobalt 60 particles) indicates extremely small probabilities that a particle of the minimum required s [ activity existed in areas accessible to the individual or the ring. A l minimum fuel fragment activity of 51 microcuries and a minimum Cobalt 60 activity of 860 microcuries would have been required. Particles approaching such activities have never been found in any area accessible to the individual or his ring. Such particles have not been found recently in spite of an aggressive survey campaign by more than 80 Health Physics Technicians over the first month and a half of the present' Unit 3 outage. During this same period there have been an estimated 130,000 person-counts by the PBM-200 personnel contamination monitors and all identified instances of radioactive particle detection have been recorded. Surveys of the individual and of associated areas and personnel during i. the periods when the individual could have been exposed, are sufficient to conclude that the individual did not receive the exposure. L Regarding the work with the crud tank pump, the recollections of the l Health Physics Technician and the worker, combined with an analysis of the instruments and techniques used, indicate that surveys were adequate to detect an irradiated fuel fragment of at least 2.5 l microCuries and a cobalt 60 particle of at least 3 microcuries. The surveys were conducted at the appropriate times and with sufficient frequency. Regarding the Reactor Coolant Pump Seal work, the worker did not enter the pump shrouds and only touched the potentially [ contaminated seal after it had been bagged in plastic to prevent contamination transfer. Since the outer surface of the bag was l subsequently carefully surveyed for radioactive particles and none were found, there is little likelihood that the protective glove covering the individual's ring became contaminated with a particle of sufficient activity to produce the reported exposure. l L

VI-1 VI. ACTION { ~) ~ As has been extensively detailed in the preceding text, no reasonable, reproducible evidence exists upon which a valid conclusion that an excessive radiation exposure occurred could be based. It is the position of Southern California Edison Company that the 511.99 rad exposure report is not valid, and that the exposure did not occur. Nevertheless, it is prudent to retain full information when dealing with matters relating to radiological health and safety. Accordingly, it is appropriate that the subject individual's personnel radiation dosimetry records reflect the occurrence of the 511.99 rad exposure report. The dose-equivalent record for the subject individual should, by definition, reflect the potential for biological harm, either stochastic or non-stochastic. From the report of the Committee on the Biological Effects of Ionizing Radiations, it is known that the spontaneous incidence of skin cancer is high, while radiation-induced cancer of the skin in general is exceedingly rare and radiogenic cancer of the extremities has never been observed. Therefore, the risk of stochastic effects nuld not be an issue were the exposure report valid. It is also % own that non-stochastic effects, such as desquamation and ulceration, are generally apparent within a few weeks after exposure. Medical examination of the individual's hand was negative for latent effects, and the individual himself reported no sensations of discomfort. Therefore, the dose to his hand, had it actually occurred, pv must have been less than 1000 rad, which is the threshold for dry desquamation. This essentially rules out consideration of future non-stochastic effects. In summation, it is maintained that no elevated exposure occurred. Were the exposure report valid, little if any potential for biological harm exists. Nonetheless, it is prudent that the individual's permanent record somehow reflect the occurrence of the exposure report. Consistent with the estimates of biological risk, and with SCE's desire to preclude any inappropriate or prejudicial effect on his employment future, a special entry of 511.99 rad will be made to the record as documentation of a special event. As a result of the exposure report and the ensuing investigation, action was also taken in the areas of; TLD results reporting and radioactive particle control. Regarding deficiencies in the exposure reporting system, the following steps were taken: All previous vendor written reports, issued from the start of the period when use of the receiving computer program was initiated, were immediately reexamined and compared with the official San Onofre records of exposure. It was determined that there were no other instances where there was a difference between the vendor hard copy and the official San Onofre records. J

r VI-2 All other exposure record related computer programs that had not (]- been previously verified and validated by the Company's Nuclear Information Systems (Computer) Group were withdrawn from service. Each program was subsequently verified and validated by.the Group and then returned to service. No problems were identified during the verification and validation process. The Dosimetry Group procedures were revised to require timely comparison of confirmatory hard copy with computer acquired data. The vendor was contacted with regard to the failure to immediately report the high reading. The vendor indicated that the failure had occurred through oversight. The terms of the purchase order were revised to emphasize the need for immediate reporting and the doses, above which immediate reporting is required, were clearly set forth. A provision was added to the purchase order to require the vendor to identify, save, and immediately send to San Onofre any TLD chips which yield abnormally high readings. Such chips are to be accompanied by all data developed by the vendor. With respect to radioactive particle control, it should be noted that extensive action had been taken previously to deal with this matter. Furthermore, at the time the report was discovered the Health Physics Division was heavily involved in enhancing the existing program in preparation for the impending Unit 3, Cycle III refueling outage. Major aspects of the enhanced program, which were in full effect as the outage started, included the following: Six hours of formal training was provided to all Health Physics Technicians, including all contractors. This training included presentations on; the source of the problem, characteristics of irradiated fuel fragments and the procedures specifically developed to deal with them. The training included several hours of laboratory, hands-on training in radioactive particle detection and identification, with special emphasis on irradiated fuel -fragments. Two hour briefing sessions were provided for involved first line supervision (and above) to explain the problem and the measures being taken to deal with it. A five page special hand-out, describing irradiated fuel fragments, explaining the problems associated with them and stating exactly what must be done to work safely with them was provided to each person who entered the Restricted Area. First line supervisors used this same document as the basis for tailboard sessions with all of their workers. Traffic flow was routed to require use of the PBM-200, personnel contamination monitors, by all workers who work in protective clothing in Units 2/3. All personnel departing the Units 2/3 radiologically controlled area are required to pass through the s ( PBM-200s. Furthermore, individuals (frisker monitors) are employed during the outage to assure that everyone uses the PBM-200s properly and to direct anyone, who causes the PBM-200 to alarm, to a Health Physics Technician for disposition. 1

VI-3 A procedure was issued to deal specifically with irradiated fuel /,i ' particle controls. This procedure features a " zone" control system V whereby the areas where fragments are known to exist or where their presence cannot be ruled out, are designated and subject to especially stringent controls. Such areas are then_ surrounded by a buffer zone, or fixed, solid physical barriers. Frequent surveys in

the buffer zone are used to verify that control over the inner zone is intact.

'A running inventory of all radioactive particles ~is maintained and provided to all managers by electronic mail and to workers by random posting to keep everyone posted on radioactive particles, their rate and method of discovery and the jobs they are associated with. Additional specialized monitors were added to the protective clothing cleaning facility to assure that adequate monitoring capability. i l O

ATTACHMENT II-1 .L PAGE 1 of 10 MEMORANDUM FOR FILE q O. January 7, 1987

SUBJECT:

Interview with Dr. Leider and Individual A re: His Possible 512 Rem Extremity Exposure Dr. Leider and R. V. Warnock interviewed the individual at about 0030 on December 13, 1986.- The interview was taped and is transcribed below. The individual was not initially. told any details of the potential hand exposure so as not.to bias his responses. Dr. Leider: You were wearing a ring badge on both hands of course. Which fingers were you wearing them on? Individual A:I wore it on the middle finger. Facing down all the time. RVW: Chest badge worn where? Individual A: Chest badge, usually I put in my pocket. RVW: Okay. Individual A:And the 5 badges, I usually tape them up high because my pants always fall down. So they usually end up awfully close to my knees or right at the bend of my knee. My ankle pads usually are right at my socks because when my pants go down they usually end up down at my ankles. RVW: PCs don't fit you either, I take it. Individual A:No. I Dr. Leider: As'far as what I'm interested in is if you can recall this time that he has given you of the 6th of October or 7th. Six to 8 weeks ago and remember the jobs you were doing. I know i that may be difficult but because apparently you have been in good health as far as we know. I know you have Kaiser coverage but have you had any problems. Individual A:About 3 weeks ago I had the flu. I had diarrhea and upset stoma ch for a weekend and a Monday. Dr. Leider: Did you see a doctor? 1

ATTACHMENT II-1 PAGE 2 of 10 MEMORANDUM FOR FILE -January.7, 1987 O Individual A: No I was going to but then it started clearing up so I just called the hospital and they told me to take Pepto-Bismol or Kaopectate and see if that would help and if not to come in. But it helped. Dr. Leider: About how long did this last? Individual A: Totally, it was Friday night, Saturday, Sunday, Monday and Tuesday and Wednesday my bowels were loose but they were controllable. About 5 days. Dr. Leider: Outside of that you haven't had any other problems? Individual A: No. Dr. Leider: You didn't have any nausea? Individual A: Just what was related to this thing. RVW: I need to say something here. We have this O odd ball TLD reading we are trying to understand. Even if the thing were real it is not a threat to you. We are not sitting here wondering about your health. 4 Individual A: Any TLD reading that would be on my red badge TLD I can't place anything when I would be even in a radiation zone except for possibly you know an area where you might catch something would be on the crud pump I might have worked on. Dr. Leider: Would you be crouching or bending over or squatting or anything in the process i of disassembling or assembling the thing? Individual A: On that it would be in front of me. I would be crouched down on the floor working while sitting on the floor. It's a small pump and l. we have it on the floor so we would be kind of sitting down or squatting down beside it. l The room is physically clean so we sit down and change bearings out. I'm not sure whether this was in that period or after that period though. But it was in the past couple O of months. I had one instance where I was on a 7 pack and all the TLDs and stuff read 20 mR I think and that's because I had it in my

ATTACHMENT II-1 PAGE 3 of 10 4 MEMORANDUM FOR FILE January 7, 1987 ( pocket. We were transporting new seals over to containment from the hot machine shop and I didn't know whether I was going to have to help transport them into containment or not so I got on the 7 pack so that I could just' dress out and do it if need be. But we had enough people to do it and I didn't have to go in. So the whole packet was in my chest pocket all the time. Dr. Leider: Were you doing this job alone aside from the HP Tech? Individual A: Two to 3 and sometimes 4 people in my crew working with me and the crew that I was assigned to during the seal change. I was never just by.myself doing things. I was always with other people. On the seal change I was the outside person except for one time when we were disassembling the spool piece which is a relatively low rad time in a period of a seal change and we were still in l respirators and plastics-I believe. I'm not sure at that time if we were in a 7 pack or whether it was just a 3 pack of rings and stuff. At that time it was just a relatively low rad type area. Dr. Leider: What area was this? Individual A: This was in the reactor coolant pump. i i Dr. Leider: What unit? Individual A: Unit 3. Dr. Leider: Okay. Individual A: This was prior to our installing the new seals. When the heat exchangers were up (high rad type area) I was an outside person. l Dr. Leider: What does that mean? Individual A: I was outside the pump shield housing which would be out in the 100 mR/hr range. Where O inside it was 5 R/hr when the heat exchanger was up in the air. The people I was working with then, I think, received 150-200 in that time zone. Outside I think I received 75-80 mR one time and 75-100 mR the second time in

g ATTACHMENT II-1 i PAGE 4 of 10 4-January 7, 1987 MEMORANDUM FOR FILE the period I was out on the platform. The platform did have a high rad area that was i" lead blanketed off. We had to kind of work around it sometimes but not right in contact with it. I had to hang chain falls in the area to swing the seals out but the only time that I even came close to that high rad area while hanging one chain fall just climbing over the top of the lead blankets. It wasn't anything extreme I don't believe. The TLD that I had with my red badge the only thing hot wise that I would work on would be that crud pump that would have possible contamination and it didn't even come up - enough at that time to warrant any super HP coverage. RVW: (Discussed particular area.) Individual A: I think A is the back room, B is the center, and C is the front. It would be B; 217B. And like I said, it really didn't warrant high coverage from the air samples and everything that was taken at that time. It was relatively low. I think that the hot spot in the room was 10 mR/hr and that was over in a corner. 4 RVW: Okay. Individual A: So it was a relatively low thing. r Dr. Leider: Now, did you at any time have any discomfort in your hands or your feet or tingling or i pain? ?^ Individual A: No. 1 I Dr. Leider: You've already told us about your episode of flu and you can't think of anything else. There are a few other questions that I'd want to ask if you could give us about a minute. l l As far as medical history is concerned I'm just about finished. If you'd like to have him go through further elaboration on what he was doing in this period you can go ahead with the questions. () ( l l 4. ~. - - _ ~..,.. _._.,.,_,y ..-.,,,,_m, ,,,_m,.,., _ .-,,_....,_,...,,,,,,,.m._,,mm-, __.__-,.._,_,,_m.-,

' ATTACHMENT II-1 PAGE 5 of 10 MEMORANDUM FOR FILE January 7, 1987 O RVW: Okay, rather than that I'll let you cover the things you need to and then I'd like to go to my office where one of the Engineers has been working for the evening. I want to sit down for as long as you will indulge us and we can stay awake and try to review your work. Individual A: (Discussion of administrative duties for remainder of evening and of work hours for next week.) Dr. Leider: So I would say if you don't plan to bring him back tomorrow morning, it can wait till Monday based on the history and what I've seen on his hands. Individual A: Is the abnormal thing on my 7 pack stuff or on my regular issue? RVW: On a 3 pack. Individual A: Well the 7 pack is ankles, knees with the () rings, etc. RVW: It's on a 3 pack. It's on a pair of rings and a chest badge combination and it's spread over 8 entries wearing that particular set. Individual A: Okay that would possibly be in the period of taking the spool piece out - the general work before we got to lifting the seals out which would possibly be a 3 pack. So that would possibly be in the area where we were getting ready to put these seals in. RVW: It looks like 4 of the entries you made on this 3 pack were in containment and probably the seal outage work and 4 were in radwaste building. You'll be able to help us understand what those were. We don't know very well yet. Individual A: Let's see. There was an area in there somewhere where I was working with fuel handling taking the gate between the fuel storage area and the transfer pool in Unit 2 and at that time we had a flea zone set up but it was nothing shown positive on the flea O zone area. We had a maximum dose on the gate when we lifted it up to 150 mR/hr I believe which is kind of nothing.

ATTACHMENT II-1 PAGE 6 of 10 MEMORANDUM FOR FILE January 7, 1987 RVW: That is surprisingly low. Individual A: Yes. Well they were deconning it as it came up. So they were washing and wiping it as it came up. It came out real clean. In fact we deconned it again laying down and we worked on it just in two pairs of gloves and PCs. Taking the old seal off and putting the new seal on. Somebody else did the grinding and welding on it. I think that was the contract i people and then we put the new seal back on it. But that was probably close in that time i zone area.

l RVW:

We've put together what we hope will be a lot of stuff to help you recall the times we are interested in. We got back the REPS and entry times and a sketch of what'was going on and that sort of thing. i Individual A: If given work orders or something like () that I could possibly... RVW: We have not gotten to MOs yet. We will 4 probably get to-those Monday. We didn't become aware of this until yesterday, evening during one of the routine checks Dosimetry i clerks do of data. Individual A: In the day time zones if I could relate it to the beginning type of seal outage then I could remember what I was doing. RVW: Dr. Leider have you covered'everything? Dr. Leider: I think I have pretty much gotten what I need. You'll have to file a 161, actually. RVW: Do I have to do that? l Dr. Leider: Only if there is evidence of occupational l injury. You have to cover the medical i expense somehow. The occupational exposure. It's part of the paperwork. Somebody will L ask. Other than that the medical part is over. I'm going to specify that the period of time you gave me that he was doing certain O work. The object you had that you were deconning was what? \\

ATTACHMENT II-1 PAGE 7 of 10 ( MEMORANDUM FOR FILE' January 7, 1987 Individual A: A weir gate. It's a dam between pools.- RVW: (Describes weir gate to Dr. Leider.) Dr. Leider:- As far as his history is concerned there is nothing further I really need. RVW: He got over skin appearances and that sort of thing? Dr. Leider-Yes, I'd like to do a more complete examination on Monday if you could send him over after he's had a couple nights sleep. I can do that Monday and the other things we were talking about - the blood count and so forth. We can draw it at that time. I don't see an emergency about doing it now or anything like that and that's all I'll be doing. So if you will give us a call Monday morning. RVW: I will get in touch with you on Monday O morning. Individual A: Do you want me to report into the shop or what? s RVW: Monday, how about if you go to the shop. We'll call tonight. We've put a hold on you Dosimetry wise we're going to keep you out of Red Badge Zones from now probably till the end of this quarter, a couple of weeks. We have to do that in a legalistic sense because we have a question about exposure and since we have this question we are obligated to NRC types not to permit you any additional exposure. Going into the Protected Area is l not a problem to us. Individual A: You mean anything from radwaste on? i RVW: Yes, past the 70' control point or past the HP control point on Unit 1 we are going to say "No" for that time period. We are going r to say "No" until the end of the year or 4 until we get it sorted out, which ever comes first. Dr. Leider: As part of the complete exam we're probably l going to want to do a whole body count even though I don't see any indication of... I'll leave it up to you. i

.. ~. ,e-ATTACHMENT II-1 PAGE 8 of 10 (~' MEMORANDUM FOR FILE January 7, 1987 J RVW: We'll do it, but it is not really relevant. Individual A: (Discussion of work hours.) RVW: (Discusses work schedule with Mr. Dr. Leider: (Questions when Mr. can come to medical.) RVW: (Wants to keep Mr. ~, on days.) Individual A: concerned about upgrade and crew. Was t'o be" upgraded thru the end of the year. Concerned ~ about income loss. Questioned if he will be reimbursed for lost income while investigation is going on. RVW: Will try to see that everything is done to see that suffers no losses. Dr. Leider: Any further questions? Explained that the things being done are baseline and routine.. O Individual A: (Acknowledges that he understands. Explains to RVW what he has to do for the l remainder of the evening. Asked where RVW's office was.) E \\ l Individual A: I get kind of a rash I guess I scratch it and when it dries out it peels and I have had that off and on depending on the stress angles and my home activities. It's happened to me for the last 4 or 5 years. Dr. Leider: Do you use solvents to clean your hands and stuff like that? Individual A: Yes, whether that's the irritant or whether it's a nervous physiological thing I don't know. I think it's more nervousness because when I drive extensively I get that too. When I go back East on a vacation or something my fingers will start little water blisters and then they peel. That's been going on for years. It did happen last month or the month before but it could have been from solvents or anything. [}

ATTACHMENT II-l PAGE.9 of 10 MEMORANDUM FOR FILE January 7, 1987 .V Dr. Leider: Are you right or left. handed? r Individual A: Right handed. I kind of. work with both hands. I write with my right hand, but I'm versatile. RVW: Let me explain to.this point. I said it is a STD-3 pack. That's a chest badge, right and left hand. That pack shows 114 mrem whole body chest, 160 mrem left hand and 512 rem right hand. 1 Individual A: (Surprised) I can see the 100 and some odd which would be about the dose I did pick up. RVW: It also matches the doses you describe in some of the other activties. We haven't seen l any like that (512 rem) and are having difficulty understanding that one. Individual A: That would be on a finger ring? RVW: Yes. Those are processed for us by a vendor O named Landauer. We've spent much of today talking to them about the QC on that badge and how did they believe it's a valid reading l on a badge. At this point they do. Individual A: I can believe that on the one ring and the badge close together because it was in the c close proximity I was working, hanging chain falls and working the outer part of the seal and what not. We did pull the seal up. That was probably on the 7 pack though rather than the 3 pack once we got the seal up. Well, maybe not working on the shroud or working on the platform. I may have been under the 3 pack on the platform. So when we transported the seal out I was in contact with the bagged up seal and moving it across f the platform. But, like I say, the other people that were working in the shroud only, I think their total dosage right now is only 370-400. That would be Individual B and Individual C I think I was working with during that period and they are kind of in the middle range for dose pick up for the seal change. They weren't high and weren't l low. l t

ATTACHMENT II-1 PAGE 10 of 10 MEMORANDUM FOR FILE January 7, 1987 iO RW: I don't remember your whole body total in the quarter but it is in that range also. Individual A: Mine was 235 range. RW: I called and couldn't get in touch with Individual D and he said he was on his way over here to talk with you. Will he arrange work for crew to do. Individual A and RW leave to go to N-50. i R. V. WARNOCK i HP Engineering Supervisor RW:mjk/ 0187-01 cc: Dr. Leider E. Donnelly R. Warnock File O , _ _. _ _ _. _ _.. _ _ _... _ _ _.. _ _. _.... _ _... _. ~. _, -... _..

ATTACHMENT II-2 O PAGE 1 OF 2 Page 2 of this attachment summarizes significant medical exposure to the cubject from previous diagnostic radiographic examinations. Notice that before and after 1978 insignificant medical exposure was received. However, during the period September 3, 1978 to November 11, 1978, considerable X-ray exposure was received. The table presents each cxamination performed during that period and includes the radiographic projection (s), views, for each of those examinations. Due to the subjects critical condition, the majority of those radiographs were exposed with a . mobile X-ray unit. Under such adverse conditions, patient. exposure tends to be much higher than similar exams performed in the controlled environment of a Radiology Department. Also included in that table are the cpproximate exposure factors which would be required to obtain those radiographs on an individual of the subject's stature. Those factors are:- FSD, the distance from the X-ray source to the subject's skin; kVp, the tube voltage; and, mas, the product of tube current and exposure time. The listed values assume the use of calcium tungstate intensifying screens and Kodak Blue Brand film. That film / screen combination was common in 1978_and necessitated much higher exposure factorn, and hence higher patient dose, than present technology. i e surface skin dose from each exposure was calculated by using a plot of

mR/ mas vs. FSD for various kVp X-rays on page 159 of the Radiological Health Handbook, January, 1970.

l Dr. P. Papin, Director of Radiological Physics at San Diego State l University, Dr. R. LaFontaine, Director of Radiation Onocology at San Diego Naval Hospital, and Mr. J. Erwin, Director of Radiological Technology-Training at San Diego Mercy Hospital, were contacted regarding expected dose / radiograph values. All three individuals validated the calculated values. 1 i I I i

ATTACHMENT Il-2 PAGE 2 of 2 x

SUMMARY

OF MEDICAL EXPOSURE ( ) . x_- l Approximate Approximate (mrem) Date Exam Views FSD kVp mas Dose / Film'- Dose / Exam Before 1978 - Insignificant Medical Exposure 9/3-5/78 Portable AP 30" 70 20 150 1050 Chest Supine (7) Portable KUB 30" 100 120 1800 1800 Abdomen Portable AP Pelvis 30" 80 100 1000 1000 Pelvis '9/8/78 Portable Upright 50" 80 16 60 60 Chest Chest Portable AP Pelvis 30" 80 100 1000 1000 Pelvis 9/9/78 Portable Upright 50" 80 16 60 60 Chest Chest 49/10/78 Portable Upright 50" 80 16 60 120 Chest Chest i 2: 9 0845 & 1115 l l 10/10/78 Pelvis AP 200 200 Pelvis Exposed 11/17/78 Pelvis AP in 200 200 Pelvis Radiology Department Ribs AP 40 Chest AP 40 (L) Ribs Oblique 40 120 (L) Ribs Total = 5610 mrem After 1978 - Insignificant Medical Exposure i Radiological Health Handbook, January 1970: Page 159 0287-02

l-ATTACHMENT II-3 PAGE 1 of 2 MEMORANDUM FOR FILF

SUBJECT:

Telephone Notes - Cytogenetic Test Results I contacted Dr. Gayle Littlefield on February 20, 1987 to review the subject test results for Individual.A. We discussed the capabilities and. limitation of cytogenetic testing. From our conversation, I prepared the following material to clarify the original report. Lymphocytes from the circulatory system are the cells which are sampled, cultured, and examined microscopically to-detect cellular level defects indicative of radiation exposure. Lymphocytes have an average lifetime of about 1000 days. Some have a lifetime as short as 5-6 weeks while others survive for many years. This average lifetime of 1000 days places a practical limit on the distance into the past which can be examined to evaluate prior radiation exposures. This limit is a function of-the magnitude of the exposure and the time since exposure. For. example, O survivors who were heavily exposed in the Hiroshima and Nagasaki atomic bombings show that a portion of lymphocytes carrying radiation induced dicentrics can survive for up to 3 decades.. A person with no radiation exposure above that from natural background is expected to show about 1 dicentric per 1000 lymphocytes. Two dicentrics in one cell for such persons occurs infrequently. Heavy smokers and persons who are occupationally or medically exposed to radiation are known to have a higher than normal background frequency of cells with dicentrics including cells with multiple dicentrics. The subject of this cytogenetic evaluation is a nuclear power plant worker with an occupational exposure of about 1.2 rad and a medical exposure of.about 5.6 rad. He was a > 1 pack / day) for about 20 years, but ceased heavy smoker ( 5 years ago. smoking about 1 The cytogenetic results indicate the following: A clinically significant whole body exposure in the range of 20-50 rads can be ruled out. Based on the observation of a dicentric frequency of 3 in 500 cells, we estimate an exposure equivalent to a whole body exposure of: O

\\. ATTACIC4ENT II - PACE, I of 2 2-MEMCFANLUM FOR FILE 4 g w 12 rad X-rays (3.4-26 rad range'at 95% confidence) 3 i ' 'or .19 rad co-60 (7-38 rad range at 95% confidence) Based on the observation of 2 dicentrice in one cell and 1 dicentric in a second cell, the subject may have received a high localized exposure in the past. it can not be ruled out that the observed cell with two dicentrics resulted from previous occupational or medical radiation exposure or past smoking habits. R. V. WARNOCK HP Engineering Supervisor RW:mjk expose 3 cc: Dr. Gayle Littlefield (ORNL) Dr. Harold Leider (SONGS Medical) 4

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g' (, ATTACHMENT II-4 PAGE 1 of 2 /7 Oak Ridge Medical and d Associated Post Office Box 117 Health Sciences Universities Oak Ridge, Tennessee 37831-0117 Div:sion January 6, 1987 Dr. Harold Leider San Onofre Nuclear Power Co. P.O. Box 128 San Clemente, CA 92672 j

Dear Dr. Leider:

1 enclose the cytogenetics report of Dr. Littlefield on your patient, As you can see from the comments, a few dicentrics were observed with an unusual distribution indicating a partial exposure to his body and indicating that he received an insignificant whole-body dose which was probably best expressed as 0. Should you have any further questions about this case, please feel free to call me. Sincerely yours, { w. C. C. Lushbaugh, Ph.D., M.D. Chief, Radiation Medicine CCL:bh Enclosure I l

ATTACHMENT II-4 g CYTOGENETICS REPORT ( PAGE 2 of 2 TO: Dr. C. C. Lushbaugh DATE 12/29/86 ,n ( tes to: Des. Fry. Ricks; A. Sipe, RRF kJ. Subject (s) name (f) REAC/TS Accident # 0889 Referring Physician Dr. H. Leider Sito of Sample Collection: ORAU Other San Onofre Nuclear Power, San Clemente, CA ~ -~Saiaple Transit: Via - Network Courier Transit Time. 024.hr.. Culture Date 12/19/86 Expscure Data: Radiation worker with a ring dosimeter reading of 512 Ren for the period of October 6-13, 1986. His ring dosimeter from the other hand and chest film badge showed sxpssure in the range of 114 to 160 mR. hand from a radioactive " fragment." He possibly received a localized exposure to the R culta of cytogenetic analyses (2-day lymphocyte cultures): Subjcct i Metaphases f Dicentrica Dicentric / cell Numb r Analyzed Observed Frequency 0 500 3* .006 (8 metaphase with 2 dicentrics) 4 B20:d cu a frequency of dicentrics/ cell the aivalent whole body dose estimate for ~~ is: Subject Name (f) Dose Estimate See Comments Ccafficients of were used to cciculcte the equivalent whole body estimates. COMMENTS: Ws cbssrved only two cells with dicentric chromosomes in our cytogenetic analyses of 500 catophnses from lymphocyte cultures from The distribution of dicentrics was

"cvardispersed" in that one of the.se two dah. aged cells contained two dicentric chromosomes.

, Such findings could be observed if the raajority of Mr. circulating lymphocytes had nst bun exposed to radiation, while a small proportion had received an excessive radiatica desa. 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 ha ot receive a clinically significant whole body dose, f f ' W j ~ L. Gayle Littlefield. Ph.D. I

ATTACHMENT II-5 PAGE 1 of 1 MEMORANDUM FOR FILE ^O January 5, 1987 Cytogenetic Test Results for Mr. E

SUBJECT:

I returned a call to Dr. C. Lushbaugh at 13:15 to discuss-the subject results. lir. Lushbaugh related that: 500 cells had been examined for chromosome aberrations. Two dicentrics were found in one cell and one dicentric in a second cell. If 3 dicentrics had been found in 3 cells, it would indicate a whole body dose of about 12 rads. The observed distribution of dicentrics indicates a whole body dose of < 5 rad and a single event in which part of the body received a large exposure. It is not possible to infer the magnitude or time of the exposure or the fraction of the body exposed. When asked about the effect of medical X-rays, Dr. Lushbaugh said they could be responsible for 2 dicentrics in one cell. He said he has seen that . instance before. When asked if exposure to a finger from a point source could cause 2 dicentrics in one cell, he said it was possible, but very improbable. I Dr. Lushbaugh closed by stating that a written report would be sent to Dr. Leider. / 1 o R. . WARNOCK HP Engineering Supervisor RVW:mjk expose 4 i cc: L. Donnelly O l i l

ATTACHMENT II-6 PAGE I of 1 Helgeson Scientific Services, Inc. Quicky Counter Results O San Onofre Mobile Quicky III 283363525 Machinist Height: 68 Weight: 185 Sex: M Age: 45 SCE 16966 Type of Count (IN/0UT/ ANNUAL /SPECIAL): SPECIAL I acknowledge receipt of this whole body count (SIGNATURE): Have you showered since last entering a contaminated area (Y/N)?: Count Date/ Time: 15-Dec-86 14:23:42 Elapsed Count Time: 30 Seconds Nuclide Action Pt nCi 2-Sis COBALT-60 11 0. O. COBALT-58 29 13. 10. MANGANESE-54 36 0. O. CESIUM-134 60 0. O. CESIUM-137 90 12. 14. ZIRC-NI0B-95 12 0. O. IODINE-131 21 1. 7. ? - No decision on nuclide

• - Above action point External counter results (Top - Net CPS; Bottom - NCi.)

1-5 0. O. O. O. O. O. O. O. O. O. 6 - 10 0. O. O. O. O. l 0. O. O. O. O. 1 1 11 - 15 0. O. O. O. O. O. O. O. O. O. 16 - 20 0. O. O. O. O. O. O. O. O. 0.+ Total external net C/S: 1 Total External nCi: 1.8 +/- 0.7 + - Proportional counter non-functions

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ATTACHMENT III-4 Psga 1 of 4 GENERAL DESCRIPTION OF THE PEN-200 I. Sys_ tem overview The Personnel Beta Monitor (PBM-200) is a radiation monitoring system designed to eliminate incompleto and time consuming hand frisking for surface contamination.. The system uses 30 high sensitivity, large area, gas flow proportional counters to examine personnel. When the PBM-200 is first turned on (or initialized), the unit performs several self' tests. If any of the tests fail, the PBM-200 will not allow monitoring to take place until the problem is corrected. If the system passes the tests, the'PBM-200 starts to accumulate background counts. In this j l mode the machine will continuously take one second readings from all of the detectors and smooth them with previous readings to update the average background value for each detector. It remains in this background accumulation mode until someone enters the machine to be counted. When a person enters the machine and is properly positioned in the booth, the unit comes out of the background accumulation mode and begins to take counts from the 30 detectors. The time period for this count is generally 10 ~ .([\\n ) seconds. When the first count is complete the person being monitored must turn 90 degrees and press the red switches at l l the sides of the booth to initiate a second count. The PBM-200 then initiates another counting period to monitor 7 the person's sides. I When finished counting, each detector will compare the number of= counts noted during the monitoring period with the i average background count obtained previously by that detector. If the number of counts noted during the i monitoring period is determined to be above the acceptable background range for that detector, the detector will alarm. This acceptable background range is determined from the i standard deviation of all the background counts obtained (as described above) up to the monitoring period. Once a detector has initiated an alarm, it will display the location of the alarming detector and the counts per second above background that caused the alarm. II. System Sensitivity y The detectors for the beta booths like friskers are designed to determine the amount of radioactive material on the surface area viewed by the detector. However, the O detector's efficiency for determining the amount of radioactive material may be affected by the location of the source relative to the detector. In order to quantify the systems' performance, we define the sensitivity as its 4 4 e, .~m v n e . w -an-- n,. - - - - - - - - .m --+--.-------ww.~a -,,-~~w,- .,-w-,,~.-- nu--o-~~ew- .~~.ea--

Paga 2 of 4 f~, e ability to detect a radioactive source positioned 3 inches from the center of a body detector and on contact with the feet and hand detectors. This represents the average distance away from the detectors that " standard man" would be when. positioned correctly in the booth. The sensitivity of the detectors can then be estimated from the source efficiency (as determined above) and the standard deviation of the background count rate for a particular detector. The system is set to alarm when the count received exceeds 6 times the standard deviation of the current background rate. The average background count rate for the hand detector is 10 cps and the average count time is 10 seconds. Therefore, the alarm point would be approximately 6 cps above background (or 360 cpm above background). The average efficiency for the hand detector on contact with a Cs-137 source is 14% resulting in a detection sensitivity of lE-3 L microcuries. This sensitivity is assumed to represent the 95% reliably detectable activity value. To verify this calculated sensitivity, several evaluations O were performed. The first evaluation involved a' review of the activity levels of localized sources identified on personnel by the beta booth. This evaluation resulted in 84 localized source. identifications in the beta booth between 1-9-87 and 2-14-87. These sources ranged in size from less than 0.001 microcuries to 1.067 microcuries. This agrees well with the minimum calculated reliably detectable activity of 0.001 microcuries. A second evaluation was performed to test the sensitivity of locati g a small particle of contamination on a TLD ring. The results of these tests are tabulated as follows. O ~ l l

Pcga 3 of 4 O No. of No. of Monitoring Alarms Source Type Activity Location Periods Received ~ Fuel Fragn.ent 1E-3 Outside of.TLD 100 100 ring, directly over TLD chip, facing inwards toward palm Fuel Fragment 2.5E-3 Underneath TLD 21 14 ring, directly behind TLD chip, inwards toward palm Co-60 1.6E-2 Outside of TLD 40 40 ring, directly over TLD chip, facing inwards toward palm Co-60 1.6E-2 Underneath TLD 9 4 ring, directly behind TLD chip, O facing inwards toward palm e O

Pago 4 of 4 GENERAL DESCRIPTION OF THE FRISKERS j System overview ~ Thyfriskerisaradiationmonitoringsystemwhichusesa15 cm active GM pancake. probe and a sealer. The probe is moved slowly (;v5cm/sec) over the surface of the area to be monitored. The full response time of the unit in this mode is approximately 20 seconds. If the number of counts noted over the monitoring period exceeds the preset alarm count rate point the unit will alarm. The preset alarm point is selected based on the background in the area where the unit will be used. The normal set points are approximately 100 cpm above background. System Sensitivity The friskers are designed to determine the amount of radioactive material on the surface area viewed by the ~ detector. Therefore, the detectors ability to detect the activity in the scanning mode will be affected by how long the material is under the view area of the detector. The longest time period, t, the detector will view a small O particle while scanning at 5 cm per sec is 1 sec. The maximum background, Nk, all wable for monitoring with a frisker is 150 cpm an5 Ehe average efficiency is 10% at 1/2" from the source, therefore, the detectable activity is estimated from: Ar 4.66 R = 4E-4 microcuries BkI Eff 2.22E6 t-l To test this value a 1E-3 microcurie. fuel fragment was i scanned (at 5 cm/sec) with a frisker in a background of approximately 100 cpm. The frisker indicated greater than i 100 cpm above background. f hk DAN MADSON /W LINDA BRA O

ATTACHMENT III - 5 PAGE 1 0F 1 P

REFERENCE:

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ATTACINENT III-6'. PAGE 1 0F l'

REFERENCE:

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() ATTACHMENT III-7 PAGE 1 of 3 MEMORANDUM FOR FILE February 26, 1987

SUBJECT:

Radioactive Particle Survey of Unit 3 Reactor Coolant Pump (RCP) Seals and Associated Equipment From October, 1986 RCP Seal Outage

REFERENCE:

On Tuesday, February 24, 1987, I surveyed the RCP seals removed from RCP MP002 and RCP MP003 during the RCP seal outage of October 1986. The instruments used were an Eberline Model RO2,. S/N 2364 and an Eberline Model RM14, S/N 5446. The dose rates on the seals were as follows: MP002 100-150 mrem /hr gamma on bottom of seal 400-1000 mrad /hr beta on bottom of seal 10-20 mrem /hr gamma on top of seal 40-80 mrad /hr beta on top of seal MP003 100-200 mrem /hr gamma on bottom of seal 500-1000 mrad /hr beta on bottom of seal 10-20 mrem /hr gamma on top of seal 50-80 mrad /hr beta on top of seal contamination surveys were performed on the seal cart (container), the outside of the bags that the seals were enclosed in before they were put in the seal cart and the seals themselves. These surveys concentrated on the identification'of radioactive particles. The contamination levels noted in this memorandum were ascertained by smearing accessible surfaces with oil impregnated masslin cloth and surveying the masslin cloth with an RO2 or RM14 as applicable. The results of the contamination surveys are as follows: 2 MP002 <1000 dpm/100 cm on the outside of the seal cart 2 10-40,000 dpm/100 cm on outside of bag There were no radioactive particles found on the cart or the outside of the bag. 100-2,000 mrad /100 cm2 on accessible surfaces of seal

I ATTACHMENT III-7 -) PAGE 2 of 3 MEMORANDUM FOR FILE February 26, 1987 MP002 (Continued) 1 radioactive particle was isolated from the surface of the seal, it was an old fuel fragment (FFrag) with total activity of 6.6E-2 microcuries. The activity of the FFrag on October 15, 1986 was 9.3E-2 microcuries. 2 MP003 <1000 dpm/100 cm on the outside of the seal cart 2 20-50,000 dpm/100 cm on outside of bag There were no radioactive particles found on the ' cart or the outside of the bag. 2 100-2,000 mrad /100 cm on accessible surfaces of seal 1 radioactive particle was isolated from the surface of the seal, it was a Ruthenium particle with total activity of 5.6E-1 I microcuries. The activity of this particle on October 15, 1986 was 7E-1 microcuries. On Wednesday, February 25, 1987, I surveyed the RCP shroud diamond plate temporary work platforms used for the RCP seal work I in October 1986. The instruments used were on Eberline Model RO2, S/N 2364 and an Eberline Model RM14 S/N 4847. The dose rates on the plates were 1-2 mrem /hr gamma and 2-5 2 mrad /hr beta. The cogtamination levels were 100,000 dpm/100 cm to 400,000 dpm/100 cm. There were no radioactive particles isolated. In addition to performing the surveys addressed above, I also had several conversations with Bud Young. These conversations centered around the logistics of the RCP seals, the RCP carts, I the RCP seal tools and equipment as well as his physical contact with the RCP seals. After the RCP seals were removed from the system they were bagged with large poly radioactive material bags. Next, the bagged RCP seals were transferred out of the RCP shroud via the installed O monorail. It was at this point that Mr. Young came into physical contact with the seals whereby he helped hand guide the seals l toward the seal carts (containers). The bagged seals were then l l l L

s. c O ATTACHMENT III-7 PAGE 3 of 3 MEMORANDUM FOR FILE February 26, 1987 lowered into the seal carts. After the carts were closed they were temporarily stored in containment for several days. The closed carts were transferred from containment to the 50' elevation Radwaste Building decontamination area. The outside dpm/100cm{andthecartsweretransferredtothesealrebuild surfaces o the carts were decontaminated to levels <1,000 rcom 37' Radwaste. This is where the carts were opened for the first time and I performed the surveys discussed earlier in this memorandum. As of February 24, 1987 the majority of the tools and equipment associated with the RCP seal work from October 1986 had been decontaminated. After these items were decontaminated they proceeded through established flow paths such as storage in REMS or being returned to the hot tool crib. The only items directly associated with the October, 1986 RCP seal work that I could positively identify were the diamond plate temporary work l platforms discussed earlier. O W j W. F. ICBY HP En ineering WFR:mjk 0287-11 cc: P. J. Knapp R. V. Warnock CDM Files 0 0 O

ATTACHMENT III-8 PAGE 1 0F 2 ett.hENCE: SO121Vil-9 9 ENCODE: CN05CA-2754 A 80 sw e r o.es Radiation Exposure Permit Page of meni o. 9 0 2 5 3 . O 0roerNo/Cwo No h 5 9 8 ne 3 \\, so /Mo No soc 4 2 Joe Locas.on un t 2/3. Biog All Ele a All Room All Other svst E

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$ystem(s, N/A Component (s) N/A Paoa C 6 J A 1 1 me Descr.ot.on MAINTENANCE SUPPORT (Special Dosimetry) -g g g g g g 4th Quarter. 1986 as.s (Entry into containaant is not allowed on this BIP) ase t, 2 I se i - P,. as con...o s j p .a s. a. G Ic.ai.-.a as G l a..

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PAGE 2 0F 2 O SPECIAL INSTRUCTIONS FOR REP 90253 THIS REP IS ISSUED TO COVER WORK OF A ROUTINE OR REPETITIVE NATURE INVOLVING LOW RADIATION HAZARDS AS DEFINED IN SOI23-VII-9.9. IF YOUR WORK MAY INCLUDE OR CAUSE RADIOLOGICAL CONDITIONS THAT ARE NOT ROUTINE AND/OR A LOW RADIOLOGICAL HAZARD NOTIFY THE REP OFFICE OR HEALTH PHYSICS FOR FURTHER EVALUATION OR ASSISTANCE. THE FLEXIBILITY ALLOWED BY THIS REP REQUIRES THAT EACH WORKER USE COMMON SENSE AND HIS/HER KNOWLEDGE OF RADIOLOGICAL WORK PRACTICES IN ADDITION TO THE SPECIFIC INSTRUCTIONS PROVIDED HEREIN AND BY HEALTH PHYSICS PERSONNEL. 1. BE AWARE OF RADIOLOGICAL CONDITIONS IN YOUR WORK AREA. CONTACT HEALTH PHYSICS FOR ASSISTANCE. 2. INFORM HEALTH PHYSICS OF YOU JOB SCOPE AND LOCATION UPON EACH ENTRY INTO A RED BADGE ZONE. 3. ALARA REVIEW REQUIRED FOR AREAS WHEPE GENERAL AREA RADIATION LEVELS ARE GREATER THAN OR EQUAL TO 50 MREM /HR. ( 4. AN REP REQUEST MUST BE SUBMITTED AND MAINTAINED ON FILE FOR ALL WORK TO BE PERFORMED ON THIS REP. A HEALTH PHYSICS FOREMAN MUST APPROVE EACH ENTRY. 5. IMTC'S ARE REQUIRED FOR ENTRY INTO AIRBORNE RADI0 ACTIVITY AREAS, EXCEPT AIRBORNE AREAS DUE TO NOBLE GAS. A HEALTH PHYSICS FOREMAN MUST APPROVE EACH ENTRY. 6. ENTRY INTO "HIGH RADIATION AREAS" GREATER THAN OR EQUAL TO 100 MREM / HOUR IS NOT AUTHORIZED ON THIS REP. 7. PROTECTIVE CLOTHING: A. FULL PROTECTIVE CLOTHING IS REQUIRED TO ENTER POSTED CONTAMINATED AREAS WITH STEP-OFF PADS UNLESS SPECIFICALLY POSTED OTHERWISE OR AN AUTHORIZED CHANGE IS MADE BY A HEALTH PHYSICS FOREMAN. B. FOR ENTRY INTO A POSTED CONTAMINATED AREA WITHOUT A STEP-OFF PAD (AREAS TOO SMALL FOR THE ENTIRE BODY TO ENTER, BERMED AREAS, ETC.) THE HEALTH PHYSICS FOREMAN OR LEAD TECHNICIAN WILL DETERMINE THE PROTECTIVE CLOTHING REQUIREMENTS FOR MAINTENANCE ACTIVITIES. C. RUBBER OVERSHOES WILL BE REQUIRED FOR THE FOLLOWING CONDITIONS. 1. FOR WORK IN WET AREAS. O 2. FOR ENTRY INTO CONTAMINATED AREAS WITH DUAL STEP-OFF PADS.

l ATTACHMENT III-9 PAGE 1 0F 2 IENCODE: CNc6CA US PA PERENCE: 5012SVn 3.3 so eo e l i Radiation Exposure Permit Paee of asp er L 9 0 I 2 5 4 tros, No /CwO No 46c 5 9 8 NO No 2 Joe Locai.on un.t 2/3 sia, All Ewa All Room All

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PAGE 2 0F 2 '~ SPECIAL INSTRUCTIONS FOR REP 90254 THIS REP IS ISSUED TO COVER WORK OF A ROUTINE OR REPETITIVE NATURE INVOLVING LOW RADIATION HAZARDS AS DEFINED IN SOI23-VII-9.9. IF YOUR WORK MAY INCLUDE OR CAUSE RADIOLOGICAL CONDITIONS THAT ARE NOT ROUTINE AND/0R A LOW RADIOLOGICAL HAZARD NOTIFY THE REP OFFICE OR HEALTH PHYSICS FOR FURTHER EVALUATION OR ASSISTANCE. THE FLEXIBILITY ALLOWED BY THIS REP REQUIRES THAT EACH WORKER USE COMMON SENSE AND HIS/HER KNOWLEDGE OF RADIOLOGICAL WORK PRACTICES IN ADDITION TO THE SPECIFIC INSTRUCTIONS PROVIDED HEREIN AND BY HEALTH PHYSICS PERSONNEL. 1. BE AWARE OF RADIOLOGICAL CONDITIONS IN YOUR WORK AREA. CONTACT HEALTH PHYSICS FOR ASSISTANCE. 2. INFORM HEALTH PHYSICS OF YOU JOB SCOPE AND LOCATION UPON EACH EN'iRY INTO A RED BADGE ZONE. 3. ALARA REVIEW REQUIRED FOR AREAS WHERE GENERAL AREA RADIATION LEVELS ARE GREATER THAN OR EQUAL TO 50 MREM /HR. O AN REP REQUEST MUST BE SUBMITTED AND MAINTAINED ON FILE FOR ALL 4 f. WORK TO BE PERFORMED ON THIS REP. A HEALTH PHYSICS FOREMAN MUST APPROVE EACH ENTRY. 5. IMTC'S ARE REQUIRED FOR ENTRY INTO AIRBORNE RADIOACTIVITY AREAS, EXCEPT AIRBORNE AREAS DUE TO NOBLE GAS. A HEALTH PH'tSICS FOREMAN MUST APPROVE EACH ENTRY. 6. ENTRY INTO "HIGH RADIATION AREAS" GREATER THAN OR EQUAL TO 100 MREM / HOUR IS NOT AUTHORIZED ON THIS REP. 7. PROTECTIVE CLOTHING: A. FULL PROTECTIVE CLOTHING IS REQUIRED TO ENTER POSTED CONTAMINATED AREAS WITH STEP-OFF PADS UNLESS SPECIFICALLY POSTED OTHERWISE OR AN AUTHORIZED CHANGE IS MADE BY A HEALTH PHYSICS FOREMAN. B. FOR ENTRY INTO A POSTED CONTAMINATED AREA WITHOUT A STEP-OFF PAD (AREAS T00 SMALL FOR THE ENTIRE BODY TO ENTER, BERMED AREAL, ETC.) THE HEALTH PHYSICS FOREMAN OR LEAD TECHNICIAN WILL DETERMINE THE PROTECTIVE CLOTHING REQUIREMENTS FOR MAINTENANCE ACTIVITIES. C. RUBBER OVERSHOES WILL BE REQUIRED FOR THE FOLLOWING CONDITIONS. O 1. FOR WORK IN WET AREAS. 2. FOR ENTRY INTO CONTAMINATED AREAS WITH DUAL STEP-OFF PADS.

ATTACHMENT 111-10 PAGE 1 OF 1

REFERENCE:

50123-VII-7.1 R.[.P 50123-Vil-7. 2 TIMI.d/O 50123-Vil-7.3 suavti t40. Q<[gg o ra fo /p.g t(ca.64t?M ..k.. RADIATION AND CONTAMINATlON SURVEY PLOT PLAN ,,,,,,,,,,,,,,,,,,,,,,,, g. aAosarrow v.a. i,i & PgWaju 24' Gryn 2/74 ista g c,i o o S 9 o gy SA /90/np teu "I* 2 3K \\ M/4 3 ZSk '20 4 S/ Y 2GB p 5 3k N/A C. 30x 1.20 7 70k L20 8 8 Nok '20 4-Q 9 folc N/A 10 Ik M/A e0 O') i/ 81< N/A ( 5g [M = b* 71 de =: -- 7g ~~ >/ .m y l g L' ., 1,.,, 8 i l [ t w a s..s w w _ s:,-,- t,--,.,_,.,--g i l i i i I' l s.. l' i l I .t..._ ...a .339r 9"",... )---~"*a ' ' ;.2 {','!_.*!" _ f-1 M s ilE V10 V.E D U V:,, /g( [,,Qlg .....i.........,......

ATTACHMENT III-ll PAGE 1 OT 1

REFERENCE:

50123-VII-7.1 R.E.P. TIME cv M' S0123-VII-7.2 p 50123-VII-7.3 SURVEY NO. /, 294 -2. oATe /o-21 it(,- ~ vacn. ( Ja ed.- L4 1 ~' RADIATION AND CONTAMINATION SURVEY PLOT PLAN ,,y RAOf ATION (mmem/hr.) p Du& &~k bi 217 A 31' u-p f'2odfinfioce,'//, a.u',. d-yo. s Zoo K -StoK dpin coamk u,,z i. f L $ B. k f cdas I$ hken lo Hddy &5KdpQ,cce,,,>k;- G A d n ~L 3-GK Sk - /O k d giupp..y floc'^ iS p c -nut. a.:. c..; u....... a ,;.,. m.,.,.,;.., r.,r a ?. 1 .., u..... <.4.. >. a. .g, I fc=Lt.a.u;d. ,.f&_ L vz_.1.L4_. __.Ws r,uviewco av: /g/g, ' d,/.. f.pe. e n o s .......,.i............,,,,,,,,

ATTACHMENT III-12 PAGE 1 OF 2 4 January 22, 1987 MEMO TO FILE J-

SUBJECT:

Crud Tank Pump Work l I In the past several days since my meeting with the two (2) NRC Inspectors concerning an alleged extremity overexposure at SONGS, I have been trying j to remember the details concerning the Crud Tank Job that I covered. To do this I logged everything that I could recall, then talked to g and s The combination of them reminding me of specific parts of the i job and my own concentration on details has increased my recollection of l the aforementioned job which is stated below. l On October 20, 1986, I was assigned to cover a maintenance crew as they-disassembled a crud Tank Pump. The pre-job survey indicated high contamination T on the exposed areas of the pump, warranting Respiratory Protection for t disassembly. Upon reaching the room. I did a survey of the room and pump -itself prior to maintenance entering. The results of my survey were consistent with those of the REP survey. At this time the maintenance men entered the pump room. I took an air sample as they began disassembly, then removed the sample to a low background area for rapid evaluation, the sample indicated i less than 200 NCPM of Airborne Radioactivity, the sample was then sent to the count room. 4 The maintenance crew completed their disassembly and laid all pump pari:s out' ~~ for inspection. I now' recall that the pieces were wiped down individually, with me checking each massilin for contamination. This part was vague to me l previously because I'had it mixed up with a similar job in the Spent Fuel Pool i Pump Room. Another reason I recall it is that I got them clean gloves to put on after they completed the parts cleaning. At no time however, do I recall either worker tearing their gloves. The survey of the pump parts indicated high contamination on several parts, but after several wipe downs, the levels l were low enough to allow them to return in the afternoon without respirators. The levels dropped from 150-200 k to approximately 20-30 k. Double gloves were worn at all times. The afternoon session in the Crud Tank Pump Room was short, after surveying an area to be drilled, the workers drilled out a pin, then I believe we exited the area. On October >21, 1986, I returned to the same room with the workers, but again it was short, perhaps 30 minutes. They were in need of parts so they exited and this was my final involvement with the job. i f _ _ --. _,,-_ 2

PAGE 2 07 2 Memo to File 2-January 22, 1987 At all times during che job I had an E-140 with me to aid in surveying both the workers and any material that was removed from the room, both maintenance men and myself performed whole body frisks upon exiting the room. FLEA Surveys were not required for this specific job, however, I used an RO-2 for my beta-gamma surveys of all pump parts. This to my best recollection is the sequence in which the job was performed and covered. (\\ ~ .a. 4 vv-- s cr HP Technician TM:db i i e *

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ATTAC} DENT III-13 FAGE 1 0F 1 MEMORANDUM FOR FILE () February 17, 1987

SUBJECT:

Correlation of Beta Radiation Levels Associated With the October 20, 1986 Crud Tank Pump Work to Fuel Fragment (FFrag) Activity

REFERENCE:

Memorandum for File from Eric Goldin dated December 2, 1985,

Subject:

Flea Detection in the Field (,6e QYc&r+csaa) \\ On Tuesday, February 17, 1987, I interviewed Mr. ! _2y regarding beta radiation levels associated with the October 20, 1986 crud tank pump job. said he clearly ~ remembers surveying (with an RO2) the pump before Mr and Mr. began the pump disasserably. Mr. also stated that he surveyed (with an RO2) the pump components as well as the workers hands during and after the disassembly process. The maximum beta radiation levels observed on the workers hands at any point was stated as "less than 200 mrad /hr for sure." Mr. stated that when he surveyed the workers hands that he concentrated on the palms of the hands. The maximum beta radiation levels observed on any of the pump components was "800 to 1000 mrad /hr." s. By assuming that these beta radiation levels were solely from FFrags and referencing the memorandum for file from Goldin dated December 2, 1985, it can be concluded that the maximum size FFrag associated with glove contaminatien is 0.5 microcuries and the maximum size FFrag associated with the pump and components contamination is 2.5 microcuries. After my conversation with Mr. I can conclude that the survey techniques he employed were clearly adequate to accurately define the beta radiation levels addressed above. / 'f V F. pIGBY HP Engineering WFR:mjk 0287-08 cc: P. J. Knapp R. V. Warnock O

m ATTACHMENT III-14 PAGE 1 0F l n u ORAD FILE SELECTION PAGE- 00) PARTICIPANT - 016966 BADGE SET. REP DATE IN TIME-I TIME-0 AREA DOSE MPC HR TERM OPR /~'50012000 76234 10/06/86 08:28 14:21 399 00080 002.12 J8A3 ZI6 (,/,h012000 76234 10/08/06 11:20 12:30 320 00060 000.02 W3AQ ZGR 03 0012088 76234 10/09/86 08:25 11:20 399 00000 000.06 W3AU VGI 04 0012000 76234 10/08/86 12:30 14:00 jUL9.00000 000.05 W3AU VGI 05 0012088 90253 10/09/86 08:18 09:19 598 00000 000.00 J8A3 Zl6 y 06 0012088 90254 10/20/86 08:12 ii:07 598 00020 000.00 W3JU 71= 07 0012000 90253 10/20/06 13:06 ~i4:58 598 00002 000.00 W3JU ZIC .08 0012008 90253 10/21/06 13:49 15:04 598 00000 000.00 W3JU ZI= NO MORE AVAILABLE E(4TER LINE NO, PAGING REQUEST, OR PF KEY-(SCEOOOB) 12/09/86 10: 17:03 APPLID=CICSTOR1,OPID=ZIF,TERh=75JR,VTAM=A175J27 l i i I I O

ATTACHf'E1T III-15 PAGE 1 of 3 TRANSCRIBED STATEMENT AUTHORED BY THE SUBJECT INDIVIDUAL On Monday. October 6, I was assigned to P-002 as Lead Mechanic along with (name(s) deleted). We tailboarded in the machine shop and decided who would work inside the shroud and who would be on platform. We all went to the 70' radwaste control point and checked in on the REP. I was out on the platform so I had a STDR3 which is two finger rings and a special TLD for my chest and a high and low PIC. I think my bin number was 56 or 57 for my 3 pack. I always put my rings on at the desk on my ring finger with the ring facing to the palm of my hand. We all went to the locker room by way of Unit 2 Penetration door and changed into modesty garments. The beta booths were working outside the locker room most of the time. Then we went up the hall to the PC issue room; my REP called for double PCs, respirator and double gloves. I always wear double gloves when I am working on anything with my hands. We logged into Unit 3 Penetration where the bookkeeper (name(s) deleted) was logging people in and out on the jobs. We got dressed except for our respirator; we put them on at the job site. We had to stage stuff for the work that had to be done, the respirator was only needed on platform near the pump i shroud. (Name(s) deleted) did all the hard work inside the shroud. I handed them tools and rounded up the lifting devices to lift the heat exchanger to replace the gaskets and bolts. I had my respirator on from about 11:00 up until we finished replacing the a gasket and putting the heat exchanger back in place with 4 bolts i i holding it down. I think the dose rate was only about SR when the heat exchanger was up. It was only up about 20 minutes from start i to finish. I took off the outside set of PCs and respirator at the step-off pad at the pump and went outside containment and finished undressing and frisked. I then filled out paperwork then went to locker room and took a shower. I always lock my rings, badge and PICS in my locker when I take a shower. I got dressed in my street clothes and walked back out to the 70' control point, frisked by hand and turned my 3 pack back into Dosimetry and checked out. I went to lunch and worked outside the rest of the shift. On October 8 we started the day about the same, except this time we were on P-003; we did about the same things before we got into j containment. (Name(s) deleted) were inside again. (Name(s) deleted) and myself rounded up lifting rigs to swing the seal out of the pump area while I was hanging chain falls and making room to work. (Name(s) deleted) was getting the crane and cask for the old seal. I didn't have to put my respirator on while working away from i the shroud. When we had everything ready, the respirator went on and we lifted the seal and transported it out of the pump, swung it l along the platform and lifted it up with the crane. The seal was in a' plastic bag from the time it came up out of the pump hole; it is still in the bag inside the cask. I was pushing and pulling it with my hands some of this time to move it around. The seal was put in the cask up on the walkway at the 65' level where you have to do it 4 ---n,-... ,.,,,--.~a ?---~~.-..--,----- - - + - - - - - - - - - -

ATTACHMENT III-15 PAGE 2 of 3 ~ on P-003 then transported to the hatch area where the other seals were stored at that time. We removed the clothing we were supposed to at the pump then walked out of containment and finished undressing and frisked and did paper work then took a shower and went outside for lunch and to work the rest of the shift. On October 9 we got to containment and couldn't go in for some reason so we went back outside. We did our return trip the same except no shower this time. We tailboarded moving the new seals into containment. I got a REP with a seven pack in case I had to go ^ in and place a seal on the pump seal. I didn't have to go in so the seven pack was in my modesty garment pocket all the time of the move. Then I went to the 37' truck bay to receive one of the new seals and take it up to containment where I. turned it over to someone-else to take inside. I went to the locker room and took a shower then went outside for the rest of the day. The second job I worked on with the 3 pack STDR3 was the crud tank = pump. (Name(s) deleted) and myself tailboarded the job in the machine shop, talked with (name(s) deleted) and found he had staged parts outside the room in the hallway for the job. We went to 70' radwaste control point to si on the REP and pick up STDR3 pack and iO went to the locker room to dress out in modesties, went to the PC respirators, then checked wi HP and got coverage lined up. We then issue counter and picked up the rest of our dress out stuff, went down the elevator to the 24' radwaste and waited for the HP to unlock the gate and let us in. The HP went in the room while we were dressing out to check it out. He told us where the hot spots were and asked us how we were going to work the job. We tailboarded with him about the job. We didn't put the respirators on until we were ready to open the system. We first uncoupled the motor from the pump and got the pump ready to open. Then, we positioned the air monitor as instructed by HP, put on respirators and unbelted the pump with air monitor on, pulled impeller out of valout, set it on floor behind and inside barrier on floor. HP frisked it with meter and told us to wipe it down; he frisked the towels we wiped with. We stacked them inside the berm until we were finished cleaning up the pump. We disassembled the pump impeller mechanical seal and Bing housing. We found a broken antirotation pin in the shaft, bad bearings and seals. We didn't have all parts on hand so we had to stop work. We undressed at the step-off pad and went outside in the hall way on the North side of the elevator where we frisked. (Name(s) deleted) had something on his shoe. HP took it off with tape. I picked up nothing with frisker, we went up the elevator to 63' then up to locker room through the beta booths to take a shower. At this time I locked my O clothes. rings and PICS in my locker until I was ready to dress in my street We went to 'O' control point, frisked out manually, and checked out, turning 3 pack in and went out for lunch.

ATTACHitENT III-15 PAGE 3 of 3 -3 O After lunch we got a drill and new pin for the pump shaft. We didn't need respirators this time, just beta face shield. We drilled the pin hole and installed new pin and left the room. This time when we frisked, nothing showed up. We went up to the locker room the same as time before, took shower, and left control point 70', ordered new parts, and finished the day. On 12-21-86 we had new seal in hand and went to 70' control point, got HP coverage and went to locker room and PC issue count, got dress out stuff, went to 24' outside room. HP opened door; we went in after dressing out. The seal was damaged trying to install; we had to stop job again and wait on new parts. We left job site same as before, went out of 70' radwaste control point and finished the rest of the day outside; HP coverage continuous throughout job. The HP coverage on the seal job was covered by rovers until the seal or heat exchanger was lifted then it was continuous until finish of the job. (Name Deleted) O 4 l e l l ( ]) } ...~. -

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ATTACHPENT IV-2 STATUS OF RING 80365, ROOM 105, AND THE SUSPECT OCTOBER 1986 Nna" V TH F SA Su M TU V TH F SA SU M TU V TH F SA SU M TU V TH F SA SU M TU V TH F 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 at 22 23 24 25 26 27 28 29 *30 31 oouo/uu' ,, /,,' ',y',' /,y,:/,:/,y', /, unu/un/ y' '/ 7yyy:/,y',,:/,yy:y' /,:/,y,'y',7g unu/u/u,,, uu;,,,o ,,,,u,,,,,, ,,,,,u,u,, hhhhhhhhhhhh' o, H ,,n,,,,,,,,,u uu/u, M u;,,,,,,,,, ,y,f ,,,vu,,,,,vu,u -h%%%'h%'H,'/%'/H/-H h '/H//' /H-H,'H/H vannonHovuonunvo, ,Qy,y,y,,y,y, 1 ' H, uvvvun,/,; yyyy (XXXXXXXHHHXXXiG(XXXH//H/v//vvvv///// y OO(XXXXXYun/XXXXX)COC'/HXXHHHHH//H//H, fhfh5MW M // /*$- "NfM 'H-h' ' - WWWtx /- 7-- \\\\\\\\ \\ \\XXN '1','1', NY by ^\\\\W#'# - -i \\\\\\\\\\\\fXN-NN'v Y" / NNNN ~~" ~ ~ ~ ' ,/H,' ,v/> kkkkkkQ-hff'

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222 22 yyr,y, yyyy E co u, -nW%',', y, WNA-W' '/A N \\ g\\\\ \\ \\XXN cH/r -75555: g g g gg yg NNNN'N/> NNNN'///' '///' oa NNNNN'///> NNNN'/H, '/H, ~.' " y y yyff-- hhh v>-3 ao ao -H -H-H-H%','/ r> -H--> D -H -> Yh% ~----- ,,,,,,,,,/ //vvvvvvvovvvvv,,vivvvvvvv/,; -/,'/% i 7-r,, 1 p:p 7> ,,yyyy/'/HHHHHH/////v///HHHHH////////////// /HHH////H, '////v///H//H//H////HH//////, f,hfhh77f'/HHH M h%'--H-h%'fi 7',%','H,%'//v/> ',' '/i',',',',% ,y/' HHH//HHHHH/vv/HH/vonn/M, yy y, 7, ,i --i 11 /HH/v///HHHH/vvv/HHHHHHHHH// y,y yI p/ 2<ac //// //////,'v, /,/v,,/,//,H,,H,,H.,H,,/,/,/,/,//H//// HHHHH////////,/s.r - .y - xx.x l l 1 RING LOCKED IN CABINET AT 70' V_Z1 ROOM 105 UNMANNED RING BEING PLACED IN PACKET SUSPECT AT VORK G RING IN USE SUSPECT IN RADVASTE BUILDING t-f RING STORED IN BIN AT 70' Lt2J RING BEING TRANSPORTED 2 RING STORED IN TLD LAB

/" ,n. ( O ATTAc RENT IV-3 RESULTS OF CONTROL CHIP EVALUATIONS AND CONTAMINATION SURVEYS Controls * - (Ring 80366) (Unnumbered Control Rin,3 A) '160 arem>-, 4-{Unnumberes Control Ri to A) (0 mrem)--+ I(Unnumbered Control Rin B) e-(Unnumbereb Control Ri in 8) (0 mren) Contamination g'WB TLD 1208ft, ,14 orem, 67 mrad) g Surveys Pands (and rings) Frisked frisked clean via PSP' Clean g 200 before and after By Clean each use. Ring storage OY ,. w e bins and lockers sub-(Lab Y'" # sequently surveyed with Personnel neoative results. \\ akin boa on d'in Transit 'Eabinet in ' Cabinet a t ' shelf at Bin 56 (or 57) when nov Kabinet in nin Transit < Wn Chip TLD Lab elevation in use (in locker TLD Lab 4n Chip J ( vendor d 70' riuring shower i hour Holder Holder i prior to exit af ter each use) Prepared Sent Receipt Moved issued Last Returned Sent Received Read by Thrown l 1 j to at to to 50 % 5 5CNGS Level Man U7e to SONGS to by vendor t t 79 TLD, Lab Vendor Vendor Away 1' <r 1 1 3r i <r wr 1, Aug.-Sept. - Sept.

• • Sept.

Sent. Oct. Oct. Oct. Nov. Nov. Nov. ? 1r 1, i' 17 1986 23 24 29 6 21 30 5 6 10 1986 1986 I986 1986 1086 I986 I9P.6 1086 1986

• "Controis" refers to TLDs which were stored with or used in conjunction with rinq 80 M5.

g ^ ATTACHMENT IV-4 y, r PAGE 1 0F 17 I g CORPORATIONna"# m "r" I I DOSE ESTIMATES FOR SOUTHERN CALIFORNIA EDISON SAN ONOFRE NUCLEAR GENERATING STATION POSSIBLE EXTREMITY OVER-EXPOSURE I I I Io By I I IT/ Radiological Sciences Laboratory 1550 Bear Creek Road /P.O. Box 549 Dak Rid e, Tennessee 37831 9 615/482-9707 February 3,1987 a RESPONSIVE TO THE NEEDS OF ENVIROfJMENTAL MANAGEMENT

, ( PAGE 2 0F 17

NERNAT!ONAL TECHNOLOGY CORPORATION

[ n ) DOSE ESTIMATES FOR v SOUTHERN CALIFORNIA EDISON-SAN ONOFRE NUCLEAR GENERATING STATION ~ POSSIBLE EXTREMITY OVER-EXPOSURE I On December 12, 1986, Southern California Edison (SCE) determined that sufficient preliminary information existed to suspect that an individual extremity exposure in excess of regulatory limits may have occurred. During October, 1986, an SCE Maintenance I individual wore two ring Thermoluminescent Dosimeters (TLD) provided and processed by a vendor TLD service. The rings were worn on five separate occasions during routine maintenance work. I Although the individual's whole body dosimetry indicated 114 mrem gamma (67 mrem skin), one of the two ring TLDs indicated an apparent right hand extremity dose of 511.9 rem, which is in I excess of the 18.75 rem per quarter regulatory limit. The TLD worn on the left hand indicated a dose of 160 mrem. To date, investigations have been unable to establish whether the I extremity exposure actually occurred. It appears equally likely that the TLD reading was anomalous, was caused by tampering, or was a true indication of dose received by the radiation detector I in the ri.ng. If the dose to the detector was real, one plausible O mechanism would be from a small fragment of fuel (fuel flea) h or 60Co particle, both of which have since been identified in the area in which this individual worked. Pursuant to 10 CFR 20.405, SCE filed a Licensee Event Report (LER) to the U. S. Nuclear Regulatory Commission on January 12, l 1987. Investigation into this incident is continuing, and the licensee will provide a complete response, in the form of a revised LER, in February of 1987. Complete analysis of this I incident will require an estimate of the "most likely" dose to the extremity of the individual in question, if one assumes that the dose indicated by the TLD response is real. As requested by SCE personnel, he following is an estimate, generated by the I Health Physics Staff of International Technology Corporation of the most probable done to the extremity of this individual. This information may be of use in revising the LER. ASSUMPTIONS During the five separate occasions on which the ring was worn, I the maximum period of potential exposure was 4.9 hours. (The ring and the individual's hands were frisked upon exit from and entry to the work area with no contamination noted. Therefore the maximum exposure pe,riod can be estimated from the longest entrance and exit time listed on the RWP's for the five occasions .l 1

PAGE 3 0F 17 INTERNATIONAL TECHNOLOGY CORPORATION or jobs.) Each time the ring was worn, it was placed on the O individual's hand with the sensitive element (TLD) on the palm I cotton glove and two rubber gloves.g were then covered with one side of the hand. The hand and rin Because the individual's whole body dosimeter and the ring l. positioned on his left hand received essentially no significant exposure, and because recent area surveys revealed that total hand irradiation (i.e. from an x-ray machine, etc.) was unlikely, I it follows that the exposure of the ring in question was the likely result of a " hot" particle or fuel flea deposited on or neartheringofthergCohavesincebeenfoundintheareain ht hand. (Both fuel fleas and particles I composed of primarily which the individual was working.) One can then describe a number of scenarios from which the most probable range of doses to his right extremity can be estimated. Four of these scenarios l are: 1 1. The source was located on top of the right-hand ring, directly over the TLD and gloves. I The source was located at the side of the ring and TLD, 2. outside of the gloves. 3. The source was located between the individual's finger l and the bottom of the ring, directly under the TLD. 4. The source was located elsewhere on the individual's hand, outside of the gloves. For all four scenarios, one of the few " facts" that exists is l that the TLD, upon readout, exhibited a response equal to an apparent dose of approximately 512 rem. Therefore, any estimates of dose to the individual's extremity must also result in a dose to the TLD of 512 rom. [The unit "ren" is used throughout this report, as it was the un;.t used in reporting the original extremity dose. The ICRP and ICRU have indicated that it is inappropriate to use units of dose equivalent for accident situations.) DOSE CALCULATIONS Beta dose to the skin was calculated by the method used in the computer code "VARSKIN". (Traub, R. J., W. D. Reece, R. I Scherpela and L. A. Sigalla, " Dose Calculation for Contamination of the skin Including the computer Code "Varskin", PNL-5610, NUREG/CR-4418 (Draf t), October, 1985. ) This calculational method is based on the tables of absorbed energy distributions around point sources in water that have been published elsewhere. 11

PACE 4 0F 17 INTE RNAT!CNA L TECHNOLOGY COR PCR ATICN (Berger, M. J., 1971, MIRD. Pamphlet No.

7. J.

Nucl. Med, l (T 12:5:5.) VARSKIN computes the radiation dose at a specified E x_,/ depth in the skin from a radiation source that ranges in size from a point to a disk of 100-cm diameter. Calculation of gamma dose at various depths (density thicknesses) was by the method of Healy. (Healy, J. W., 1971, Surface Contamination: Decision I Levels, LA-4559-MS, Los Alamos Laboratory, Los Alamos, New Mexico.) I Total done to the skin was obtained by summing the beta and gamma doses as described above. In all cases, the total dose was calculated for a one microcurie particle or flea, resident on or near the ring for 4.9 hours. (An SCE estimate of the composition i of the fuel flea is shown in Appendix A.) This dose per microcurie value was then used to determine the most probable activity of these particles for each scenario, while still I insuring that the TLD received the required 512 rem. The area of the TLD was estimated to be 0.3 cm2 for the top and bottom surfaces, and 0.03 cm2 for the side surfaces. (These areas, and I all density thicknesses used in the calculations were provided by SCE personnel after physical measurement of all components of the type of ring and the type of gloves worn by the individual in question.) Appendix B contains a summary of results for all four of the scenarios listed above. Appendix C contains the results of done calculations using different annumptions. V

SUMMARY

OF RESULTS If one assumes that the response of the TLD in real, the question then becomes; "To what range of donen could this individual havo l been exposed?" From the summary of results, shown in Appendix B, the lowest possible done to the skin would occur only if a fuel flea was deposited on top of the ring, directly over the TLD and l outside of the gloven. This value in approximately 45 rom, for a 1 51 uci fuel flea. The highest possible dono would be the threshold for nonntochantic effects in skin. From UUREG/CR-4297, (Rocco, W. D., R. Harty, L. W. Drackenbush, P. L. Robornon, "' Extremity Monitoring: Considorations for Uno, Donimator placement, and Evaluation", NUREG/CR-4297, PNL-5509, Pacific Northwant Laboratory, Richland, Washington, Decembor,1985), the dono required for induction of nonstochantic offects in skin in as follown: 111

PAGE 5 0F 17 INTEDNATIONAL TECHNOLOGY CORPOR ATION I EFFECT THRESHOLD DOSE (RAD) Erythema 200 to 600 Dry Desquamation 800 to 1100 Moist Desquamation 1300 to 2000 Ulceration 2000 to 2500 Since the individual in question exhibited no observable effects I at the time of a physical examination of his hand (which took place approximately two months after the potential exposure occurred), and also reported that he noticed no effects prior to I that time, it follows that the dose to his hand would not have exceeded 1100 rad, which is the upper limit for induction of dry desquamation. Because the dose could have been delivered to the palm of his hand, the individual may not have noticed reddening I of a small area of the skin. Therefore, the threshold dose for erythema was not considered as the upper limit in this case. In summary, the estimated absorbed dose to this individual, in light I of the assumptions listed above and the known facts, probably lies somewhere between 45 and 1100 rad. l RECOMMENDATIONS By definition, dose equivalent assignment should be proportional I(s to the risk of adverse health effects to the individual, either ) for medically discernable damage in the short term, or the risk \\/ of cancer in the long term. In the case of the SCE individual, although there was no observable damage to his hand, if the dose is real, he has increased his risk for skin cancer in the future. Unfortunately this risk is not known. For a number of populations ex, posed to sufficient radiation doses (over all or large fractions of their bodies) to cause erythema within days, none have shown an excess number of skin cancers when compared with non-exposed populations. Therefore, what done should be recorded in this individual's dosimetry record? (For a review of the options, see Appendix D.) There are three relevant sources of information in this possible over-exposure of an extremity: 1. The individual in quantion exhibited no nonstochastic effects as a result of thin incident. 2. Upon readout the TLD in his extremity donimator (ring) gave a re,sponso that was equivalent to a done of approximately 512 rom. 3. The maximum exposure time was estimated to bo 4.9 hourn. c iv i

g PAGE 6 OF 17 INTERNATIONA !. TECHNOLOGY COR POR ATIO If items two and three are true, then the actual absorbed dose to 1 cm2 of basal cells at a depth of 7mg/cm2 in this individual's hand lies somewhere between 45 rad and 1100 rad, as stated above. Selection of a singl.e number in this range is difficult as it is dependent upon the assumptions that,are made. There is no firm ) evidence to support a specific dose equivalent within this range. Unless the TLD reading can be discredited, it is our opinion that SCE radiation protection staff have no alternative but to record 512 rem as the extremity dose in the dosimetry records of this individual. From ICRP 26 and other documents, we know that this record entry will, of course, grossly over-estimate the risk of f" stochastic effects in this individual, but there is no further I regulatory guidance and insufficient dosimetry information to support any other dose equivalent assignment' I I 6 l l l v

PAGE 7 07 17 INTERNATIONAL TECHNotDGY CORPORATION APPENDIX At FUEL FLEA COMPOSITION O 7sotoDe fraption of Mix Sr-89 0.006 Sr-90 0.041 Y-90 0.041 Y-91 0.015 Zr-95 0.024 Hb-95 0.024 Ru-103 0.001 Ru-106 0.031 Rh-106 0.031 Ca-137 0.031 Ba-137 ** 0.031 Co-144 0.306 Pr-144 0.306 Pm-147 0.108 Sm-151 ** 0.001 Eu-155 ** 0.00174

• • Not consilored in calculation of beta dono d

- - ~. _ _, _

PAGE 8 0F 17 INTERNATIONAL TECHNOLOGY CORPORATION /7 APPENDIX B:

SUMMARY

OF RESULTS FOR THE FOUR SCENARIOS ] 1. Source located on top of the ring, directly over the TLD and gloves: The density thickness over the TLD, which includes two rubber gloves, one cotton glove and the ring itself is 163 mg/cm. From 2 I a one microcurie fuel flea (see Appendix A for the most likely composition of the flea as estimated by SCE personnel), the beta dose to the 0.3 cm2 TLD element is calculated to be 10.011 rem by the VARSKIN method. I rem by the Healy method. The total dose is 10.030 rem /uci. From The gamma dose is calculated to be 0.018581 a one microcurie 60Co particle, positionod over the TLD for the same period of time, the beta dose is calculated to be zero rem, I the gamma dose is calculated to be 0.59336 rem, and the total dose is calculated to be 0.594 rem /uci. Source activity needed to deliver 512 rem to the TLD: 51.05 uCi fuel flea or a 861.95 uCi 60Co particle I Resultiggdosetothebasalcellsoftheskinatadepthof 7 ng/cm averaged over 1 cm, 2 O V 45.12 rem (51.01 uci fuel flea) or 502.52 rem (861.95 uC1 60Co particle) I 2. Source located at the side of the ring, outside of the gloves: The density thickness through all absorbing media to the TLD for this scenario is 381 mg/cm. From a one microcurio fuel flea 2 l located at the side of the ring, the bota done to the 0.03 cm2 TLDis3.405 rom,thegammadoseis0.01gOrom and the total dono is 3.423 rom For a one microcurio Co particle, the bota done is zero/uci. rom, the gamma dono is 0.506 rom, and the total done l is 0.586 rem /uci. Source activity nooded to deliver 512 rom to the TLD: 149.58 uCi 873.72uCi{uolfloaora OCo particlo l Resulti g dono to the basal cells of the skin at a depth of 7 mg/cm averaged over 1 cm, 2 i 847.00 rom (149.50 uci {tjCo particlo) ol floa) or 520.74 rom (873.72 uC1 vil

PAGE 9 0F 17 !NTE3NAT!ONA L TECHNOLOGY COR POR ATION I' ( ) d 3. Source located between the individual's finger and the ring, directly under the TLD: The density thickness through the back of the ring to the TLD for -I this scenario is 83 mg/cm. From a one microcurie fuel flea 2 located between the finger and the ring, on the palm-side of the hand, the beta dose to the 0.3 cm2 TLD is 18.999 rem, the gamma I dose is 0.01870 rem and the total dose is 19.018 rem /uci. For a one microcurie 60Co particle, the beta dose is zero ram, the gamma dose is 0.596 rem and the total dose is 0.596 rem /uci. I Source activity needed to deliver 512 rem to the TLD: I 26.92 uCi fuel flea or a 859.06 uCi 60Co particle I Resulting dose to the basal cells of the skin at a depth of 7 mg/cm2 averaged over 1 cm g 2 597.84 rem (26.92 uCi fuel flea) or 17,907.11 rem (859.06 uCi 60Co particle) Because of the negative results for frisking performed by this I )j individual upon exit from the work area, this scenario presents a low probability event. 4. I Source located elsewhere on the individual's hand on the outside of the gloves. NUREG/CR-4297 states that "The response of the skin to ionizing I radiation is also influenced by the size of the region irradiated. Research shows that the radiation dose required to produce a given. level of injury increases as the area of the I field is reduced below a critical value." This document also sites the work of Charles and Wells, (Charles, M. W., and J. Wells, 1900, "The Development of criteria for Limiting the Non-Stochastic Effects of Non-Uniform Skin Exposure", in Radiation I Protection. A Svntomic Approach to Safety, Vol. 1, pp. 39-43, Pergamon Press, Oxford, Great Britain.) which demonstratou a threshold done of creator than 40,000 rad to induce crythoma in I pig skin, using a 204T1 beta source of 10-2 cm3 area. In other words, for a given radiation done, as the area irradiated decreason, the peripheral collo become more important to I recovery. If this area in sufficiently small, the germinal epithelial cells inside the area may be totally annihilated, and yet there will be little, if any, observed injury due to prompt recovery and repair by proliferation of colin from the edges of i the irradiated area. lp V vili .4

PAGE 10 0F 17 '[ INE RNATIONA L TECHNOLOGY COR POR ATION I With this in mind, one might postulate that the individual Q involved in this incident may have had a fuel flea or 60Co source lI'~'j deposited elsewhere on his hand which irradiated such a small area that no nonstochastic effects were observed; yet it delivered up to 40,000 ram to that area, and, at the same time, caused a TLD response which corresponded to a dose of 512 rem. If a 60Co particle which delivers at least 40,000 rad to a 10-2 2 area is deposited on the outside the individual's gloved cm I hand, the associated beta radiation (0.0965 MeV Eave) Will deliver no dose to the skin. As stated in U. S. Nuclear Regulatory Commission Inspection and Enforcement Notice 86-23, "A I hot particle on the skin produces a very steep dose gradient with the dose dropping off rapidly as distance from the particle increases." However, the gamma radiation from the particle would irradiate a significant area of the hand in order to deliver 512 I rem to the TLD. Had this occurred, nonstochastic effects would have been observed. I 10-2 cm If a fuel flea which delivers at least 40,000 rem to an area of 2 is deposited on the outside of the individual's gloved hand, in order for this fuel flea to also deliver approximately 512 rad to the TLD in the individual's ring, the actual area l irradiated must, again, be much larger than 10-2 cr.2 This is due to the density thickness of the side of the ring through which the radiation must penetrate in order to reach the TLD, and I V -... in observable.nonstochastic effects.over that larger are E _. to the range of the radiations. This condition would also result O I Since the individual in question did not suffer any apparent nonstochastic effects, the possibility of a physically undetectable, extremely high dose being delivered to a small area of his skin away from the ring, while still delivering 512 rem to l the TLD, is unlikely for either fuel fleas or 60Co particles. 1 I I I I lO u I

PAGE 11 0F 17 INTE RNAT!ONA1. TECHNotDGY COR POR ATION I APPENDIX C:

SUMMARY

OF OTHER DOSE CALCULATIONS ~ 1. Source located on top of ring, directly over TLD: Cell area (cm2). Thickness rem /uci (fleal rem /uci (ISgq). (ma/cmL} 1 253 2.731 0.591 1 286 2.300 0.590 1 466 0.885 0.583 1 499 0.719 0.581 10 253 0.333 0.591 10 286 0.286 0.590 10 466 0.124 0.583 b 10 499 0.106 0.581 0 0.3 163 10.030 0.594 1 2. Source located at the side of the ring 1 122 5.668 0.596 1 154 4.683 0.594 10 122 0.640 0.596 10 154 0.539

0. N 0.03 381 3.423 O.586 3.

Source located betwoon extremity donimator and finger, behind TLD 1 7 22.208 20.845 1 40 10.906 0.991 x

PAGE 12 0F 17 INTERNATIONAL TECHNOLOGY COR PORATION 10 7 2.491 2.625 10 40 1.168 0.638 l 0.3 83 19.018 0.596 E Il. I I ' I I IO l l 4

I I

!l 1 1 O x1 I

PAGE 13 0F 17 INTERNAT CNAL TECHNOLOGY CORPORATION I APPENDIX D: OPTIONS FOR RECORDING OF DOSE Of importance to SCE is the assignment of a dose equivalent between 45 and 1100 rem to the individual in question's personnel dosimetry record. Since the record may be used to estimate the I, risk of stochastic effects to this worker, the inclusion of doses resulting from " hot" particle deposition will overestimate the actual risk. The ICRP has addressed this concern in Publication 26, paragraph 33, with the following statement: "... the Commission believes that, for late stochastic effects, the absorption of a given quantity of radiation energy is ordinarily likely to be less effective when due to a series of " hot spots" than when uniformly distributed, because of high doses in causing I the loss of reproductive capacity or the death of cells. Thus, with particulate radioactive scurces within a tissue, to assess the risk by assuming a I homogeneous dose distribution would probably overestimate the actual risk" With this in mind, the following possible options are available I for assignment of radiation dose equivalent for this individual, assuming, of course, that the dose to the TLD was realt 1. V Determine the most likely averaged absorbed dose to one square centimeter of skin, designate it as the total body " dose-equivalent", and place it in the individual'n dose equivalent record. This option places a dose-equivalent on record which I can be, typically, thousands of times higher than that for which actual biological effects are expected under the most conservative assumptions. As described in I Appendix B, a hot particle on the skin can result in an t absorbed done to a cmall area of banal cells of thousando of rado, yot no visible effects are observed. Also, the literature documents that excess skin cancer ll is not observed in populations exposed to high radiation donos to the whole body. Thereforo, any real "done equivalent" in vanishingly small. This option would not only overcatimate the risk, it would also give, in later yearn, a basin for an inaccurate probability of causation for any cance.r this individual might develop. (It is important to note that 40 l percent of all pornons of ago 65 have or have had skin cancer.) 2. Determino the average absorbod dono to ono squaro contimeter xil

E 5 PAGE 14 0F 17 INTERNATIONAL TECHNOLOGY COR POR ATION (or ten square centimeters as recommended in the proposed revision to 10 CFR 20) and designate it as the dose equivalent to (G) the extremity. If some dose equivalent must be entered in this individual's dosimetry record, this option, for one I* square centimeter, is supported by the majority of existing regulations and guidelines. (The ten square centimeter area has the virtue, at present, of being used at other NRC Licensee facilities and of being I listed in the proposed revision of 10 CFR 20.) 3. Determine the most likely absorbed dose to an area of this individual's skin having a radius equal to the maximum range of the radiations involved, divide this by the total area of skin on the affected extremity, designate and record this as the dose I equivalent to the extremity. This is not an unreasonable representation of actual l risk in the case of beta irradiation of the skin. Further if the doses were so hi h that signs and symptoms developed at the irrad ation site, the I dosimetry and medical records would provide a basis for continued observation. However if the particle were composed primarily of 60co, the distance of concern of the 1.17 and 1.32 MeV gamma ray photons in skin is O significantly higher than that of beta particles. v I 4. Determine the most likely average dose to the basal cells of the epidermis of the hand and assign this value to the dosimetry record for the extremity. This closely represents the dose of concern and hence the risk of cancer, assuming that the risk is not zero. It fills any need for some ultimate entry into the 'I individual's donimetry record. I 5. Record the most likely absorbed done to one squaro contimotor of skin an a special entry for modical guidance only, but ontor nothing in the dono-equivalent record. l This option provides for the advantagon of option (3) relative to medical evaluations, but avoids the extrapolation to effecta einowhere in the body. 6. Ansign the value indicated on the extremity donimotor to the donimatry record for dono equivalent to the extremity. xi. n-_ e_--

INTE!!NATIONA1.TECHP Y CO ATION This option must be used if there is insufficient information to support any of the other options. It is (O standard industry practice to use this option for extremity doses in the absence of other valid information which could discredit the dosimeter readings. I I I .I f I 'E 'E ,1 I ll O xi. l i

FEB 19 '87 04:21 IT CORP.-RSL #615 482 9729 P.1 PAGE 16 0F 17 February 19, 1987 Ms. Linda Bray Southern California Edison San onofre Nuclear Generating Station P. O. Box 128 San Clemente, California 92672 Dear Lindat As per your request of February 1s, 1987, we have performed a bit of follow-up analysis of our report to you entitled " Dose Estimates for Southern California Edison San Onofra Nuclear Generating Station Possible Extremity Over-Exposure". In that report, we used the computer code MVAR8 KIN" to determine a range of possible particle sises that would irradiate the TLD in the subject's extremity dosimeter to approximately 512 ren. As you know, " VAR 5KINN was written to compute the radiation dose at a specified depth in the skin from a radiation source that can ( range in size from a point to a 100-en diameter disk. Using l " VAR 8 KIN" to estimate TLD response after irradiation by a " hot particle" is an approximation only, because the code does not l simulate deposition of energy through the entire volume of the l TLD. l From our prior calculations, we found that if one places a 51.05 uCi fuel flea on top gf the extremity dosimeter, or ring, the dpse delivered to 0.3 cad TLD at a density thickness of 163 ag/cm is 512 rom.2 The resulting dose to 1 cad of basal cells at a depth of 7 ag/cm for the individuni in question would be 45.12 ram. Again, this is not an unreasonable estimate, as the TLD thickness is small with respect to the range of the beta particles and gamma ray photons. Nowever, TL dosimeters do show a non-negligible change of response depending upon the direction of radiation incidence. In Anolled Thermeluminemeanna cosimetry blr M. Oberhofer and A. Scharmann, the directional dependence of T2 is shown to vary by incidence changes from 08 to 90gactor of a 10 when the angle of of the top surface. Recent experimental evidence acquired by you at SCE/80NG8 confirms this fact. It is my understanding that when you irradiated a si lar ring to that worn by the individual in question with a gsr source, the TLD response dropped by a factor of 10 when the source was moved from the top of the ring to the side of the ring. From your experimental evidence, we can infer O that if a 51 uCi fuel thea can result in a TgD response of $12 rem when placed on top of the ring (183 mg/cm ), a slo uci fuel Isson.arere.unoad.ro sou s49.oakn: doe. tenne stest.eis 4:397o7 l a

• '
• FEB 19 '87 04:22 IT CORP.-RSL #613 482 9729 P.2 INMRNATIONAl. UCIO$dfdQMPChlAT!ON O

the side of the ring (381 mg/cm ). flea can also result in a TLD esponse of 512 rea when placed at From ' previous calculationL made with "VARSKIN", we found that the dose conversion factor (rea pe microcurie) for 1 cm3 of positionedatthesideofthering,g/cm{, ~ basal celle at a depth of 7 a when a fuel flea is i is approximately 5.7 rea/uci. Therefore, for a 510 uci fuel flea, the resulting dose would be approximately 2900 ren. From NUREG/CR-4297 be sufficient to cause, ulceration over 1 onweknowthatthisdpseof2900remwould of the individual's hand. However, our report set the upper limit for most likely dose to this individual at 1100 rea. (since the individual in question exhibited no observable effects at the time of a physical examination of his hand two months after the potential exposure occurred, and he reported no effects prior to that time, it follows that the dose to his hand could not have exceeded 1100 i rom.) This information is for your lamediate use. Because of the short time frame we have not treated this issue in depth. We can, however, com, pile a more complete analysis of this situation for you and send it on by Federal Express, although I hope that the information contained herein will suffice for you" immediate needs. Please let me know if there is anything furtner we can ( o do. t sing 9 rely, lk ./ 3 carol D. Berger y I i O i

t A1TACHMEKr IV-5 PAGE 1 0F 2 s MEMORANDUM FOR FILE ) 4 ' February 19, 1987

SUBJECT:

Correlation of Beta Radi'ation Levels Ar.sociated With the Unit 3 Reactor Coolant Pump (RCP) Seal Work During October, 1986 to Fuel Fragment Activity

REFERENCE:

Memorandum for File from Eric Goldin dated December 2, 1985,

Subject:

Flea Detection in the Field After reviewing the radiation and contamination surveys for the month of October, 1985, I determined the maximum beta radiation levels associated with the Unit 3 RCP seal work to be as follows: RCP MP001 4,800 mrad /hr RCP MP002 1,000 mrad /hr [ RCP MP003 420 mrad /hr RCP MP004 6,000 mrad /hr By assuming that these beta radiation levels were solely from fuel fragments (FFrags) and referencing the memorandum for file from Goldin dated December 2, 1985, it can be concluded that the maximum size FFrags associated with the RCP seal work were as follows: RCP MP001 10.6 microcurie RCP MP002 2.2 microcurio RCP MP003 0.9 microcurio RCP MP004 13.2 microcurio a The correlation from bota radiation levels to FFrag activity was calculated as follows: The 4 microcurio FFrag discussed in Mr. Goldin's memorandum road 500 mrad /hr window open and 55 mrad /hr window closed. By subtracting tho window closed reading from the window open reading and multiplying by i i -am

d PAGE 2 0F 2 c MEMORANDUM FOR FILE February 19, 1987 the standard beta correction factor of 4, the observed dose rate of the 4 microcurie FFrag can be established as 1780 mrad /hr. Therefore, the FFrag activity for each 1000 mrad /hr equals 2.2 microcuries. I v)' b l W. F. /RIGBy HP Engineering WFRimjk 0287-09 cc P. J. Knapp R. V. Warnock E. M. Goldin D e

r/ ATTACHMENT IV-6 L PAGE 1 0F 1 y Estimate of Co-60 Particle Activity Based on Dose Rate Measurements To determine the maximum activity co-60 particle which could have been detected by a careful field survey in the work area for the RCP and CTP work: A) Gamma Exposure rate measurements from closed window RO2 readings. Distance from source 3 feet. X = 6CE where X is in Rad /hr 2 d C is in Curies E is in MeV d is in feet The activity of a point source with a 3 foot exposure reading of 20 i mR/hr is C = (20E-3)(9) = 13 millicuries (6)(2.25) B) Beta dose rate measurements from open minus closed window readings f-~ (corrected for beta response RO2 readings. /g j (Activity) 4.8 Igd = RO2 reading hr mci 13 The factor of 13 is a size (geometry) correction for small particles. For an RO2 reading of 1 Rad /hr, the activity of co-60 would be 3 microcuries. It is therefore concluded that accurate survey techniques could detect Co-60 particles of 30 millicuries in a 20 mr/hr (gamma) field and 3 microcuries in a 1 rad /hr (beta) field. / O

ATTACHMENT IV-7 PAGE 1 OF 11 O February 19, 1987 R. V. WARNOCK E. H. DONNELLY

SUBJECT:

Evaluation of Histogram Data Introduction Through a series of experiments and data compilation, four separate frequency histograms have been generated. They are: 1. Unit 3 Containment, Radwaste Building, and Personnel Contamination Fuel Fragment Particles 2. Unit 3 Containment, Radwaste Building, and Personnel Contamination Cobalt particles 3. Percent Residual Values of SCE Generated Test Rings 4. Percent Residual Values of SCE Generated Test Rings,100R to 1000R i For the first two histograms, certain values have been postulated that under certain geometric conditions could possibly explain the 512 Rem exposure. Statistical tests were used to evaluate whether these postulate values could belong to the distribution seen here at SONGS. For the last two histograms, statistical ~ tests were used to evaluate whether the 11.55% residual could belong to the experimental distribution of SCE generated test rings. (See Section V) Hypothesis With the guidance and assistance of Dr. Chong Chiu, Assistant Manager Station Technical, certain methods were used to test the following alternative hypothesis (H,). l H,: that the postulated values / observed percent l residual belong to the distribution H,: that the postulated values / observed percent residual do not belong to the distribution O a e_ I e .-~e, .,.----m-4-vr, a,, v--~-, ,..w. ~, -n w. .-.,e,rr~..--------,w, - - - ~ -. ----wr- -. -

PAGE 2 0F 11 Method of Analysis T-Test. This test.is also known as Grubb's Test. This test can be used when a single outlier is suspected. It will calculate the number of standard i deviation away from the mean that the extreme value lies. If the result is larger than the tabulated value, it can be rejected as one outlier. I T = !**~*I S where T = the T-test statistic Xe = the extreme value of interest x = the mean of the distribution S = the standard deviation of the distribution R-Test. This test is also known as Dixon's Test. This test is the ratio of how far the extreme value is from each end of the distribution. Xe - Yn-1 r= Xe - Y1 where: r = the test statistic Xe = the extreme value of interest Yn = the end value of the distribution Y1 = the first value of the distribution If this ratto is larger than the tabulated value, it can be rejected as an outlier. Chauvenet's Criterion. In this test a value may be rejected as an outlier if, for sample size n, it has a deviation from the mean greater than that corresponding to a 1/(2n) probability. IXm - x) s where: Xm = value of outlier i = sample mean S = sample standard deviation If the value calculated exceed the tabulated value, it may be classified as an outlier. 6

~ PAGE 3 OF 11 R. V. WARNOCK E. H. DONNELLY February 19, 1987 O Tchebysheff's (Chebychev's) Theorem.possible probability of observing a spe This theorem will calculate the maximum 1 = Xe - x S max probability = */18 where: 1 = number of standard deviations out Xe = extreme value x = mean of distribution S = standard deviation This calculated probability must then be divided by 2 to account for a two tailed distribution. The mean and standard deviation used were calculated from the histogram and do not include the extreme values. For the R, T, and Chauvenets tests, the mean and standard deviation of the data was calculated from the histogram with the extreme value included. THE RESULTS Cobalt - 60 The Cobalt-60 distribution shows three distinct modes, the last mode was used in the calculations; this mode consisted of intervals 6 (SE-1 to <10E-1) to 11 (IE+2 to <5E+2). R-Test Calculated Tabulated n x S Xe r r 15 82.82 224.5 860 0.710 0.488 RCP, top of ring 15 173.35 569.3 2218 >0.710* 0.488 CTP, top of ring 15 607.95 2249.8 8737 >0.710* 0.488 RCP, side of ring 15 1577.62 5811.0 22532 >0.710* 0.488 CTP, side of ring l This test was used with an alpha of 0.005. I i

• Since the most restrictive extreme value can be classified as an outlier by the R-test, it follows that these values may also be classified as outliers.

O

PAGE 4 0F 11 R..V. WARNOCK. I E. H. DONNELLY February 19, 1987 -T-Test Calculated Tabulated n i S Xe t t 14 82.82 224.5 860 3.46 2.66 14 173.35 569.3 2218 3.59 2.66 14 607.95 2249.8 8737 3.61 2.66 14 1527.62 5811.0 22532 3.61 2.66 This test was used with an alpha of 0.01. Chauvenet's Criteria Calculated Tabulated n i S Xe t t 14 82.82 224.5 860 3.46 2.10 14 173.35 569.3 2218 3.59 2.10 14 607.95 2249.8 8737 3.61 2.10 14 1527.62 5814.0 22532 3.G1 2.10 Tchebysheff's (Chebychev's) Theorem n i 5 Xe 1 Max Probability i 14 27.30 67.06 860 12.42 3.24E-3 14 27.30 67.06 2218 32.67 4.63E-4 i 14 27.30 67.06 8737 129.88 2.96E-5 l 14 27.30 67.06 22532 335.59 4.44E-6 The mean and standard deviation were calculated from the histogram without inclusion of the Xe value. Fuel Fragments R-Test Calculated Tabulated n i S Xe r r 313 0.3580 2.950 51 0.853 0.372 RCP, top of ring 313 0.6168 7.470 132 >0.853* 0.372 CTP, top of ring 313 4.976 84.416 1496 >0.853* 0.372 RCP, side of ring 313 12.521 217.708 3858 >0.853* 0.372 CTP, side of ring This test was used with an alpha of 0.005

• Since the most restrictive ext.reme value can be classified as an outlier by R-test, it follows that these values may also be classified as outliers.

l l

PAGE 5 0F 11 R. V. WARNOCK -E. H. DONNELLY February 19, 1987 ( T-Test Calculated Tabulated n i S Xe t t 313 0.3580 2.950 51 17.17 3.01 313 0.6168 7.470 132 17.59 3.01 313 4.976 84.416 1496 17.66 3.01 313 12.521 217.708 3858 17.66 3.01 This test was used with an alpha of 0.01 Chauvenet's Criteria Calculated Tabulated n i S Xe Chauvenet Chau'venet 313 0.3580 2.950 51 17.17 3.14 313 0.6168 7.470 132 17.59 3.14 .313 4.976 84.416 1496 17.66 3.14 313 12.521 217.708 3858' 17.66 3.14 O Tchebysheff's (Chebychev's) Theorem t n i S Xe 1 Max Probability 312 0.1957 0.6944 51 73.16 9.34E-5 312 0.1957 0.6944 132 189.81 1.39E-5 312 0.1957 0.6944 1496 2154.1 1.07E-7 312 0.1957 0.6944 3858 5555.6 1.62E-8 % Residual R-Test l Calculated Tabulated n i S Xe r r 173 0.5185 0.9489 11.55 0.826 0.372 l 85 0.6828 1.2715 11.55 0.834 0.372 This test was used with an alpha of 0.005 ~ O

PAGE 6 0F 11 R. V. WARNOCK E. H. DONNELLY February 19, 1987 T-Test Calculated Tabulated i S Xe t t n x 173 0.5185 0.9489 11.55 11.63 3.01 85 0.6828 1.2715 11.55 8.55 3.01 This test was used with an alpha of 0.01 Chauvenet's Criteria Calculated Tabulated n x S Xe Chauvenet Chauvenet 173 0.5185 0.9489 11.55 11.63 3.02 85 0.6828 1.2715 11.55 8.55 2.74 Tchebysheff's (Chebychev's) Theorem n i S Xe 1 Max Probability 172 0.4474 0.4411 11.55 25.17 7.89E-4 84 0.5488 0.4615 11.55 23.86 8.78E-4 Conclusion i 1. The postulated activity (both fuel fragment and cobalt-60) can be classified as outliers with the distribution of material observed here at SONGS. 2. The 11.55% residual can also be classified as an outlier when compared with the experimental data generated here at SONGS. O' w ~ DANIEL MADSON Health Physics Engineering DM:MJK Expose:0568Y Attachments O

=. l' PAGE 7 OF 11 REFERENCES 1. " Applied Statistics - Analysis of Variance and Regression," 0. J. Dunn and V. A. Clark, New York, John Wiley,1974, pp 339-340. 2. " Basic St'atistics Methods for Engineers and Scientists," J. B. Kennedy and A. M. Neville, New York, Thomas Y. Crowell Company, Inc., 1964, pp 180. t i e f 9 ~ O~ i I -.__--------#_.,__.-_.,.._..,--_._-_..-m_.,.-n-,- ...,m,-.-.._,.____... m._,,-,,,,--,-,.--..-,w,...,-

Number of Data Points Generated 3 o o o 1 I t t 1 0.000 to 0.105 3 0.105 to 0.205 -4 0.205 to 0.305 [ 9. 0.305 to 0.405 -4 O = O.405 to 0.505 8 g 0.505 to 0.605 CD o 0.605 to 0.705 - Cu M M m 0.705 to 0.805 - A 8 it 0.805 to 0.905 - CO C "C Oo E 0.905 to 1.005 - CD M <: hMh 1.005 to 1.105 - Cu = m a 1.105 to 1.205 - CO O" 0 E9 1.205 to 1.305 - O m-( O e 1.305 to 1.405 - CD N@ _~ C 1.405 to 1.505 - N 3m 1.505 to 1.605 - O 8 O 1.605 to 1.705 - O { ~ 1.705 to 1.805 - O O O O 1.805 to 1.905 - N m 7 1.905 to 2.005 - U 2.005 to 2.105 - O 2.105 to 2.205 - O O l 11 30 8 20Vd

Number of Data Points Gencreted 5 Y Y h 0.000 to 0.105

1. g N

0.105 to 0.205 o 0.205 to 0.305 0.305 to 0.405 c"n N 0.405 to 0.505 - o 0.505 to 0.605 - Z 0.605 to 0.705 - G Z M T g 0.705 to 0.805 - G o o 00 h 'm b 0.805 to 0.905 - A c o5 0.905 to 1.005 - CD E o b 1.005 to 1.105 - A e ae 1.105 to 1.205 - G gga 1.205 to 1.305 - O O{ 1.305 to 1.4057 O 1.405 to 1.505 - C4 E c 1.505 to 1.605 - ~ 1.605 to 1.705 - O 1.705 to 1.805 - 0 1.805 to 1.905 00 7 1.905 to 2.005 - 2.005 to 2.105 - 2.105 to 2.205 - O O II do 6 30Vd

Number of Particles Identified i e o, o o y 1E-3 to < SE - X g SE-3 to < 1E to O 1E-2 to < SE 03 5E-2 to < 1E - 1E-1 to < SE CD C D SE-1 to < 1E O - C0 F e 8h 1E O to < SE O - c) 4h D hk h ^h 693 5E O to < 1E+1 to Qfg-USS E55 8o $, 1E+1 to < SE+1 - F@g SEE ~ p~r i gg SE+1 to < 1E+2 - K y 1 a s N' EEt I I o 1E+2 to < 5E+2 - @$m aGg -sa SE+2 to < 1E+3 - O RCP frogment o 860 Ci* h, @y. E 1E+3 to < SE+3 - O CTP fragment e 2218 yCt* W SE+3 to < 1E+4 - o 1E+4 to < SE+4 - o SE+4 to < 1E+5 - O 1E+5 to < 5E+5 - o SE+5 to < 1E+6 - o O 11 20 01 3DVd

i Numbar of Particles Identified Y O E 1E-3 to < SE $ C er E SE-3 to < 1E $ 2 0 1E-2 to < SE N Cn SE-2 to < 1E $ 1E-1 to < SE $ C p 'U o) F SE-1 to < 1E O - S CD cg> e c @h 1E 0 to < 5E 0 - c) Eh P4 69y$ 7$ SE O to < 1E+1 - G pf g-gaa c3 a 3k[ 1E+1 to < SE+1 - O 58.4 F m g[ g (gg SE+1 to < 1E+2 O RCP fragment e 51 Ci** 3 [ g g- $g$Q l I

• 1 1E+2 to < SE+2 - O OTP frogment o 132 pCi **

E3m 5Eo v 5 "- I G pG g 3, SE+2 to < 1E+3 - O g, m (D oc C C: 1E+3 to < SE+3 - O 4 5-Uta SE+3 to < 1E+4 - 0 1E+4 to < SE+4 - O o 4 2: ou SE+4 to < 1E+5 - O N 1E+5 to < SE+5 - O s :;- {$ SE+5 to < 1E+6 - O o5 kn.$ h un 11 30 II 30Vd

, TEB e3 '87 05:03 IT COPP.-RSL e615 482 9729 P.1 ATTACHMENT IV-8 ~. PAGE 1 OF 3 s N bt Z. YiSb? ? CbPORA I N February 5,1987 Mr. Richard V. Warnock Southern California Edison San Onofre Nuclear Generating Station P.O. Box 128 3an Clemente, CA ylo/l

Dear Mr. Warnock:

As part of our evaluation of the possible causes of the high TLD readings for the extremity dostmeter worn by Mr. records on residual readings of Harshaw TLD-100 ribbons.in october 19661 reviewed my As I mentioned to you in a recent phone conversation, the residual reading of such TLDs is generally less than 11 of the inttf al reading f f the reader is functioning properly. A brief report is attached which describes an experiment which confirms ny observations. Although this report is for a single experiment it is typical of residual readings of TLD-100 ribbons at large doses. Information on such residual readings please contact me.If you need additional I have consulted with Ms. Carol Berger on the dose evaluation for this individual and I concur with her report to you dated February 3,1987. If any additional information becomes available in this case please contact either of us so that we can re-evaluate the assfgnable dose for this individual. Sincerely, b John R. Frazier, Ph.D. Sr. Radiological Scientist Enclosure JRF/rd O 1550 Bear Creek Road. PO Box 549. Cak Ridge. Tennessee 37831 615 462 9707 __-.__ - __.,-._-... --~.-. -, _-.._,

~ .___m.__ ,FEB.05 '87,05:07 IT CORP.-RSL #615 482 9729 P.1 PAGE 2 0F 3 I RESIOUAL REA0!NGS OF THERNDLUMINESCENT DOS!ETER$ O John R. Frazier, Ph.D. February 4,1987 During December, 1973, a survey of a medical accelerator at the National Institutes of Health (NIH) in Bethesda, Maryland was perfomed by personnel of the US Food and Drug Administration (FDA). I coordinated the dosimetry of that survey. As a part of the survey, thirty-six (36) thermoluminescent dostmeters (TLDs) were irradiated on December 18, 1979, at the National Bureau of Standards laboratory in Gaithersburg, Maryland. All dosimetert were 11thfum fluoride (Harshaw type TLD-100) high-senettivity ribbons. An absorbed dose of 100 rads was delfvered to each TLD positioned in the center of a 20 cm x 20 cm x 20 cm Luette phantom. Dr. Christopher Soares perfomed the irradiations using one of the NOS Cobalt-60 calfbration units. Following frra-diation, the dostmeters were taken to the FDA dostmetry laboratory in Rockville, Maryland where they were read with a hot gas reader (Harshaw ATLAS Reader). s Each TLD was read on the morning of December 20, 1979. Results of those reading j are given in Table !. Approximately four hours later, each TLD was re-read with no additional preparations to determine the " residual" reading or second i readout. These results are also givon in Table !. The ratio of the residual reading to the inttial reading was calculated and is ofvon in Table !. These findings for an absorbed dose of 100 reds from Cobalt-60 gamma rays are in good agreement with numerous data for other absorbed doses and other sources. A l residual reading of 0.54 - 1.05 is to be expected for these TLDs exposed in this dose range. l From sy experience, residual readings in excess of 15 generally fndicate a problem with the reader. I have found this to be attrfbuted to insufficient j heating to the TLD, light leaks into the photomultipiter (PM) tube, or electronic noise in the PM tube and current integrator electronics. i (O l t e e

FEB 05,'87 05:08 IT CORP.-RSL 4615 482 9729 P.2 PAGE 3 0F 3 1 TABLE I IN!TIAL AND RES! DUAL'READINS$ 0F TLO-100 R!880NS TLD Tr4y Initial Residual Residual Batch No. Position Reading

• Reading **

rnitfal x 1005 070-01 42 12.99 UC 54.2 NC 0.42 070-01 43 13.16 UC 72.7 NC 0.55 070-01 44 12.75 UC 63.0 NC 0.49 070-01 45 12.89 UC 73.7 NC 0.57 070-01 46 13.15 UC 61.0 NC 0.46 070-01 47 13.02 UC 66.9 NC 0.51 070-01 48 12.92 UC 68.2 NC 0.53 070-01 49 13.13 UC 61.2 NC 0.47 070-01 50 12.96 UC-68.4 NC 0.53 070-02 42 13.01 UC 64.0 NC 0.49 070-02 43 12.95 UC 74.1 bc 0.57 070-02 44 13.36 UC 67.3 NC 0.50 070-02 45 12.74 UC 87.2 NC 0.68 070-02 46 13.48 UC 63.5 NC 0.47 070-02 47 12.77 UC 65.3 NC 0.51 070-02 48 13.51 UC 81.2 NC 0.60 i 070-02 49 13.15 UC 61.7 NC 0.47 ~ 070-02 50 13.29 UC 77.3 NC 0.58 i 070-03 42 13.24 UC 74.3 NC 0.56 070-03 43 13.72 UC 68.2 NC 0.50 070-03 44 13.23 UC 77.9 NC 0.59 070-03 45 13.35 UC 73.3 NC 0.55 i i 070-03 46 13.24 UC 54.0 NC 0.41 070-03 47 13.64 UC 66.2 NC 0.49 070-03 48 13.04 UC 61.6 NC 0.47 070-03 49 13.41 UC 72.1 NC 0.54 070-03 50 13.27 UC 66.3 NC 0.50 1 070-04 42 14.16 UC 74.8 NC 0.53 j 070-04 43 13.55 UC 79.7 NC 0.59 070-04 44 14.02 UC 78.1 NC 0.56 070-04 45 13.58 UC 85.5 NC 0.63 070-04 46 14.44 UC 66.7 NC 0.46 l 070-04 47 13.96 UC 66.6 NC 0.48 j 070-04 48 13.64 UC 67.8 NC 0.50 i 070-04 49 14.26 UC 118.8 NC 0.83 070-04 50 13.63 UC 85.1 NC 0.62 Average = 0.53 STO. Dev,= 0.08 UC = micro-coulombs = 10-4 C 1

• • NC = nano-coulombs = 10-' C

\\'O i I 4

T ATTACHMENT IV-9 1 OF 23 REPORT ON TEST IRRADIATIONS DONE USING RING BADGES Submitted to: Richard Warnock Southern California Edison Company Health Physics, Bldg. N50 P.O. Box 128 San Clenente, California 92672 Submitted by: Phillip Plato The University of Michigan School of Public Health Ann Arbor, Michigan 48109 February 20, 1987 l l l t l 1 l I

( O TABLE OF CONTDfrS Page INTRODUCTION 1 MrrHODS AND MATERIALS 2 Ganma Rays 3 Xhp 3 Beta Particles 3 Neutrons 3 RESULTS 4 Gansna Rays 4 X Rays 5 O Beta Particles 5 Neutrons 19 DISCUSSION 14 Data Frar. This Study 14 Data From Previous Study 15 Data Fran Eberline 17 Descrepancy From Previous Reports 18 CDNCLUSIONS 19 APPENDIX A. Intters of transmittal between us and . that reflect our attempts and partial success in obtaining processing assistance fran APPENDIX B. Results reported by for the ring badges irradiated for this study. O c

INTRODUCTION Mis report is intended to add a4ditional information for the investigation of ring badge no. 89365. mis ring badge was worn by a worker at SONGS during October,1986, and subsequently showed an apparent dose of 512 rad. Ring badge no. 89365 showed an initial response of 5,129,999 nc and a residual (second reading) of 593,399 nC. Approximately 5,999 nc of the residual reading was due to a calibration dose of 350 mrad from Sr/Y-99 as part of routine procedures. Neglecting this minor caponent, the residual was about 11.5% of the initial response. During my first visit to en December 18, 1986, I was told that a residual of 11.5% was normal for LIF elements processed with laser TLD reader. I was shown a dose-response graph that showed about a 194 residual from 30 rad to 1999 red, but I was not permitted to have a copy of the graph, My trip report (dated Decenber 31, 1986 and revised en January 7, 1987) reflected the statement by that an 11.5% residual is within the normal range of residuals that they observe. This asstnption is discussed on page 11 of my report, and it is the basis of my second conclusion on page 13. l "2. It is likely that the large response for ring badge no. 89365 was caused by ionizing radiation. mis conclusion is based primarily on the 11.5% residual observed when the element was read the second time." l [ Discussions with Tonny Johnson of the Naval Research Laboratory and Nels Johnson of Iberline Instrument Conpany, both of whom are involved with radiation dosimetry using Lir, did not substantiate contention ~ that 11.5% is a normal residual. Se general opinion is that 9.5% to 1.9% g is the normal range, and 11.5% is empletely abnormal. l

. _ - = - - l 2 ( In order to investigate residual responses, we irradiated a number of ring badges to X rays, ganna rays, beta particles, and neutrons. W ese ring badges were sent to for processing on January 26, 1987. We requested that process same e.ements with their laser TLD reader and others with their hot nitrogen gas reader. returned all the ring badges unprocessed on January 27, since they felt that our request would involve too much work on their part. We negotiated a reduced number of ring badges and empletely eliminated the use of a hot nitrogen gas reader. This was disappointing to us since it is likely that ring badge no, i 80365 was annealed on a hot nitrogen gas reader during September,1986 before the badge was sent to SONGS (the laser reader was first put into service during October, the month during which a worker at SONGS wore ring badge no. 80365). We returned the ring badges to for processing on January 28. Appendix A contains the three letters of transnittal between us and We purpose of this report is to doement the irradiations we performed and the initial readings and residuals produced by The report also documents a discrepancy found in my second report to SONCS (dated January 7,1987), and some relevant irradiations done by the Eberline Instrument Company. ME3 HODS AND MTERIALS During January and February,1987, we irradiated a number of ring badges to various radiation sources. Each ring badge contained one LiF element. All irradiations were done with the ring badges mounted on a 30 m ( by 30 m by 15 m thick (whole body) tissue-equivalent phantom. A brief j description of each source is given below. i I 4

3 ,m (('d ) 1 Ga mn Rays A 400 Ci cesium-137 source was used for all gama ray irradiations. Wis source is a beam irradiator manufactured by J.L. Shepherd and l Associates. The phantom was located 100 cm from the source. W e exposure rate for this source was measured with an Exradin transfer standard ionization chamber that had been calibrated for cesiunt-137 by the U.S. National Bureau of Standards (NBS). X, Rays One standard fBS X-ray technique, EI, was used for these irradiations. This technique has an average energy of 74.6 kev and is produced with a tube potential of 150 kVp and filtration of 5.0 m Al plus 0.25 m Cu. We exposure rate for this source was measured with an Exradin transfer standard ionization chamber that had been calibrated for technique E I by the NBS. Irradiations were done with the ring badges at 100 m frm the X-ray tube. Beta Particles A thallium-204 source, purchased from Amersham, was used to irradiate ring badges to medium-energy beta particles. Irradiations were done with the ring badges positioned at a distance of 54 an from the source. An extrapolation chamber had been used to measure the absorbed dose rate fran 2 this source at 54 an at a depth of 7 mg/an in tissue. The extrapolation chamber was intercompared with the one at NBS. The measutt.d absorbed dose rate is corrected on a daily basis for radioactive decay. Neutrons Wo neutron sources were used for these irradiations. W e first is a californium-252 source at the center of a 30 cm diameter sphere of heavy [ ( water and cachium. %e neutron mission rate from this source was measured by NBS. This mission rate is the basis for the calculated dose equivalent

i 4 (\\~J rate at the irradiation distance of 50 m. We dose equivalent rate is corrected on a daily basis for radioactive decay. The second neutron source used for these irradiations is a thermal beam port frcrn The University of Michigan's 2 MW research reactor. The flux of thermal neutrons was measured as 6 x 105 2 rv's per cm. The factor given in 10 CFR 20 to convert from flux to a dose equivalent rate of 2.5 mrenV'h is 670 for thermal neutrons. %us, we assume that the thermal neutron dose equivalent rate at this beam port is 2,239 mrerrt/h. There is also a ganma ray dose equivalent rate of about 1,000 mrem /h at the beam port. RESULTS The ring badges irradiated for this study were processed by during February, 1987. The results were sent by to SONGS. We received a copy of the results from SONGS on February 19, 1987. Wese results are contained in Appendix B. The results are sunmarized below. Grrrna Rays Table 1 shows the responses and residuals (in units of nanocoulombs) observed from irradiating ring badges to doses from cesium-137 that ranged from 10 to 1000 rad. We ring badge in question (no. 80365 from October, 1986) showed a response of 5,120,000 nC. We were especially interested in reproducing this response, which we did as shown in Table 1. We 6 ring badges irradiated to 500 rad from cesium-137 all showed a response similar to that of ring badge no. 80365. However, although the residual from ring badge no. 80365 was 11.51, all of the residuals shown in Table 1 ranged frm 0.01% to 0.07% for the irradiated alements. Table 2 shows the results of our attenpt to document the ( l reproducibility of processing techniques. A dozen ring badges had been irradiated to each of two relatively low doses (500 mren and 1000 l 1

5 (O mram) fra cesitan-137. We had asked to read these elements twice and then to develop element correction factors using their routine procedure of irradiating the elements to 350 mrad from SrM -90. We intended to examine the average reported doses for the two groups of ring badges with element correction factors applied. Unfortunately, only read the elements twice and did not irradiate them to SrM-90 and produce element correction factors and doses as requested. %us, we cannot comment on ability to generate doses reproducibly. i The results of Table 2 show two interesting items. First, the reproducibility of the uncorrected initial element responses is good. The standard deviation among each group is about 13% of the average response. Second, the residuals for these rehtively low doses range from 0.23% to 0.724, considerably less than the residual of 11.5% observed for ring badge no. 80365. X_ Rays Table 3 shows the responses and residuals observed from irradiating ring badges to doses from MFI X rays (average energy of 74.6 kev) that ranged from 100 to 1000 rad. We responses bracketed the response of 5,120,000 nc from ring badge no. 80365. However, although the residual from ring badge no. 80365 was 11.51, all of the residuals shown in Table 3 range from 0.00% to 0.12% for the irradiated elements. Beta Particles Table 4 shows the responses and residuals observed from irradiating ring badges to doses of medium-energy beta particles from thallium-204. 2 Wese doses ranged from 129 rad to 362 rad at the shallow depth (7 ng/m ), [( %e responses were considerably less than the response of 5,120,000 nC frw 4 ,.. ~ _ ,_.___-,_.-_-_w._m, _,----_-_____.__w._ -r_-~

T 6 (' Table 1. Responses of LiF ring badges irradiated to gama rays from cesium-137. 1 Deep Dosimeter Dose Response (nC) Nunber (rad) First Second Residual (t) l 82466 9 218 30 13.76 82467 0 243 26 19.79 82468 9 268 28 10.45 82411 le 97,699 33 9.93 j 82412 10 192,199 36 9.94 t 82413 199 839,999 47 9.91 82414 100 1 59,999 453 9.94 i 82415 259 2 99,999 1,342 9.95 82416 250 2, 29,999 600 9.93 i 82417 599 6, J 00,999 4,005 0.97 i 82418 599 5,439,999 1,509 9.93 82419 599 " L19,999 4,J55 9.96 82429 599 fi, 859,999 3,561 0.97 l 82421 599 f,719,999 501 9.91 82422 599 !,540,999 881 0.92 j 82423 759 8,689,999 1,114 9.91 82424 759 7,889,999 3,883 9.95 82425 1999 13,260,999 3,634 0.03 i 82426 1999 13,320,999 1,428 9.91 i k ) i 1 (( t i l

7 ( ) Table 2. Reproducibility of LiF ring badges irradiated to cesium-137. Deep Dosimeter Dose Response (rc) Number (mrem) First Second Residual (t) 82439 599 5,799 34

9. 60 82431 500 4,728 29 9.61 82432 500 4,352 25 9.57 82433 500 5,990 29 9.58 82434 500 4,389 27 9.62 82435 500 4,179 25 9.69 82436 500 4,393 26 9.69 82437 500 5,100 29 9.57 82438 500 5,700 26 9.46 82439 500 5,800 42 9.72 82440 500 5,600 29 9.52 82441 500 4,700 28 9.58 82447 1900 9,100 32 0.35 82448 1900 11,700 28 9.24 82449 1990 8,800 26 9.39

/s 82450 1990 9,190 26 9.29 C\\j 82451 1990 19,309 28 9.27 82452 1990 7,600 27 9.36 82453 1900 8,900 35 0.39 82454 1900 19,600 34 9.32 82455 1000 11,190 26 p.23 82456 1990 7,900 36 9.46 82457 1990 19,000 32 0.32 82458 1000 8,100 31 0.38 4 1 l I I

8 ( Table 3. Response of LiF ring badges irradiated to ifI X rays. i Deep Dosimeter Dose Response (rf) Number (rad) First Second Residual (t) 99116 9 219 39 18.57 99191 9 187 39 29.86 99196 0 185 25 13.51 99108 199 1,319,999 159 9.91 99129 199 1,119,999 565 9.95 99194 199 1,949,999 1,223 0.12 99193 499 5,829,999 2,193 0.04 99113 499 6,259,999 59 9.99 99115 499 6,669,999 823 9.01 99193 1999 12,749,999 3,196 9.92 99196 1999 15,699,999 4,944 0.03 99197 1999 13,519,999 3,936 9.93 i l 1 l<O l

l Table 4. Response of Lir ring badges irradiated to beta particles from thallium-294. Shallow l 4 Dosimeter Dose Response (rc) Number (rad) First Second Residual (t) 99194 129 60,900 38 9.96 99112 129 75,000 32 9.94 l 99118 129 73,400 34 9.95 99119 354 172,200 42 9.92 99117 354 226,400 42 0.02 99119 354 246,400 58 9.92 99102 362 244,000 198 9.04 99111 362 289,200 168 9.96 99114 362 211,190 55 9.03 99195 362 179,100 327 9.18 99197 362 181,190 323 9.18 99198 362 179,290 236 9.13 8 4 i t I t i I I l t i i ..m..-

10 ring badge no. 80365. As with the photon irradiations shown in Tables 1, 2, and 3, the residuals shown in Table 4 ranged from 9.92% to 0.184, significantly less than the residual of 11.5% for ring badge no. 89365. Neutrons Table 5 shows the responses and residuals observed from irradiating ring badges to doses from californium-252 moderated with heavy water. .1 t.mfortunately, the responses were not as large as the 5,128,999 nC from ring badge no. 89365. As with the photon and beta particle irradiations, the residuals shown in Table 5 are small. Only the two ring badges (80997 and 89998) that were irradiated to 3,999 mram neutrons showed residuals that ( exceeded 11. targe residuals were not obserad at higher doses. Table 6 shows the responses and residuals observed from irradiating ring badges to mixtures of neutrons and game rays from moderated californitan-252 and game rays from cesium-137. The responses appear to be linear conbinations of the component radiation types, as would be expected for any Tt.D. For example, the three ring badges (89129, 82445, and 82446) irradiated to 7,949 mram neutrons from californiure-252 averaged 91,199 rc as shown in Table 5. Se two ring badges (82411 and 82412) irradiated to 19,999 mram gama from cesiure 137 averaged 99,859 rc as shown in Table 1. Se latter response would have been 4.2 times larger (419,400 nC) for an irradiation of 42,999 mrom. %us, the anticipated response for ring badge no. 82472 in Table 6 is 519,500 nc, very close to the actual response of 537,499 rc. Table 7 shows the responses and residuals observed from irradiating ring beiges to thermal neutrons and gama rays from a beam port at he { University of Michigan's 2 MW research reactor. We were fortunate to have bracketed the 5,129,999 nc response from ring badge no. 89365. All of the

1 11 ("f) Table 5. Response of LIF ring badges irradiated to neutrons plus V gama rays from californium-252 moderated with heavy water. Dosimeter Dose Equiv. (mram) Response (nC) Number Neutron Gama First Second Residual (%) 82461 0 0 321 29 9.93 89997 3,999 549 32,699 435 1.33 89998 3,999 549 42,499 1,134 2.67 80099 5,999 999 55,800 167 9.39 89199 5,999 999 67,299 91 9.14 89191 5,099 999 78,299 297 9.26 89129 7,049 1,269 97,699 294 .9.39 82445 7,949 1,269 99,399 149 0.14 82446 7,949 1,269 76,499 91 9.12 = 1 e s .t' 5 l i l 1 l

u,/ 12 o / o ,c J ' p ,1i Table 6. Response of LiF ring badges irradiated to neutrons plus gama rays from moderated californium-252 and to game rays from cosiw137. '/ Californium-252 Cs-137 Dose Dosimeter Dose Equiv. (mrem) g. (mrem) , Response (nC) Number Neutron Game Gama First.1 Second Residual (%) I 82470 7,949 1,269 3,499; 126,400 67 9.95 82471 7,949 1,269 6,998 144,590 57 9.94 82469 7,949 1,269 21,999 / ~ 282,200 84 9.93 82472 7,949 1,269 42,000 537,490 256 9.95 1 / '/ )s' ( l j l / e e 'm I r l / i sl I 1 I j' i i I h

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w 3 LU ). Pesponse of LiF ring badges irradiated to ther:nal neutrons Table 7. plus gama rays frca a beam port of a research reactor. i h Dosimeter _ Dose Eq.'(mrem) Response (rc) Ntnber Neutzc7 Gama First Second Residual (%) c \\ s 82439 t 10 0 \\ 1,153 31 2.69 4 82450 0 0 1,063-32 3.01 l80105 2,239 1,000 2,140,000 , 7,300 0.34 .80106 2,239 1,000 .'y1,999,000 2,298 0.12 80107 2,239 1,000 '1,4f0,000-3,624 0.24 80111 4,480 2,000.. 6,930,000 23,400 0.34 80112 4,430 2,000" 7,120,000 7,100 0.10' 80113 4,480 2,000 9,000,000 13,000 0.14 80117 6, 720 3,000 9,39J,000 6,100 0.07 80118 6,720' 3,000' 15,040,000 19,100 0.13 80119 6,720 3,000 J12,630,000 14,306 0.11 82473 6,720 3,000 i12,720,000 3,952 0.03 82474 6,720 3,000 9,790,000 4,400 0.04 82475 6,720 .3,000 13,710,000 21,260 0.15 82476 6, 720 3,000 12,130,000 8,400 0.07

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14 (( residuals shown in Table 7 range from 0.03% to 0.34% for the irradiated elanents. These residuals are considerably less than the 11.5% residual observed for ring badge no. 80365. It is interesting to note the large response (about 1,100 nC) of the unirradiated controls show in Table 7 campared to the unirradiated controls (about 233 nc) for the other types of radiation. mis difference reflects ~ the excellent sensitivity of LiF for thermal neutrons. DISCUSSION Date Frcrn This Study Tables 1 through 7 show the responses and residuals of a number of ring badges that had been irradiated to gama rays, X rays, beta particles, and neutrons. W e ring badges were processed by using their laser TLD reader. %ese ring badges were read a second time in the laser TLD reader without the usual irradiation to 350 mrad from Sr/Y-90 that is used to generate an element correction factor. Otherwise, these ring badges were apparently treated the same as ring badge no. 80365. Many of the initial responses shown in Tables 1 through 7 are reasonably close to the initial response of 5,120,000 nC reported for ring badge no. 80365. I However, none of the residuals shown in Tables 1 through 7 are as large as the 11.5% residual reported for ring badge no. 80365. In fact, the largest residuals obssrved in this study were 1.33% and 2.67% as shown in Table 5. %e next largest residual for an irradiated element is 0.72% for ring badge no. 82439 in Table 2. We average residual for all of the 87 irradiated elements shown in Tables 1 through 7 is 0.23%. (' Table 8 shows a sumary of the conversion factors (in units of nCAnr'ad) observed for the ring badges processed for this study. For the I

f 15 cesitzn-137 irradiations, this conversion factor is about le nCAnrad. Wis is in good agreenent with the calibration factors of around 0.1 mracVnC (or le rCAnrad) that routinely observes using ganma rays from cesium-137. Table 8 shows that a conversion factor of about le nCAnrad is also applicable for X rays using the MFI technique (average energy of 74.6 heV) and for neutrons from californium-252 moderated with heavy water. Two interesting exceptions to a conversion factor of about 10 nCAnrad are observed in Table 8. The conversion factor for medium-energy beta particles from thallium-204 is about 0.6, and the conversion factor for thermal neutrons is about 1500. These conversion factors, used as a divisor, offer a wide range of calculated doses for ring badge no. 80365. The initial response of the element from this badge a s 5,120,000 nc. If this response was caused by ionizing radiation, then the conversion from response to dose is highly dependent on the type of radiation involved: Conversion Factor Radiation Type (nCAnrad) Dose (rad) Photons, 75 to 662 kev 10 500 Cf-252 neutrons 10 500 Thermal neutrons 1500 3 Medium-energy bet s 0.6 8,000 Date From Previous Study l In my report to SONGS dated January 7,1987, Appendix D contains the results of ring badges processed by in my presence on January 5, 1987. Wese ring badges had been irradiated at SONGS to various types and 1 l doses of radiation wnich were unknown to me. Among the 41 elements with an l (v initial response of 30,000 nc or greater, the average residual was 1.3% of the original response. This is in reasonably good agreenent with the

.=. _. 16 Table 8. Sumary of the conversion factors observed from the data in Tables 1 through 7. Dose Conversion Factor Radiation h (rad) (nCAnrad) Ganna (Cs-137) 0.5 9.93 1 9.43 le 9.99 100 9.40 250 9.42 500 11.41 750 11.04 1000 13.29 X Ray (M I) 100-11.53 499 12.51 1000 13.98 j i Beta (T1-204) 129 0.54 354 0.61 362 0.59 Q Neutron (Cf-252) 3.00* 10.70 (k/ l 5.00* 11.62 l 7.05* 11.12 Neutron (Cf-252) 11.82** 10.69 Plus 15.32** 9.43 Gama (Cs-137) 29.32** 9.62 l-50.31** 10.68 Neutrons (thermal) 2.24*** 831 l 4.48*** 1711 6.72*** 1834 The dose contribution of 18% from ganna rays has been subtracted from the total response (nC) using a conversion factor of le nCAnrad. 1he total dose used includes doses from Cf-252 neutrons, Cf-252 gannas, and Cs-137 gamas. The total response (nC) was also used. The dose contribution of 45% from gamna rays has been subtracted from the total response (nc) using a conversion factor of 10 nCAnrmJ.

17 I average residual of 0.234 for the 87 elements of the current study as shown in Tables 1 through 7. Se average residuals of 1.3% and 8.234 are significantly less than the 11.5% residual observed for ring badge no. 80365. Data From Eberline During February,1987, I spoke several times by phone with Nels Johnson arx! Stan Waligora of the Eberline Instrument Company at Santa PW, New Mexico. I proposed an hypothesis to explain the initial and residual responses observed for ring badge no. 80365. Se hypothesis is that the laser TLD reader malfunctioned during the initial reading in a way that caused the laser to stay on for two or three times the normal heating i cycle. Se normal heating cycle lasts about 1.2 seconds which takes the O. A longer than temperature of the LiF element from ambient to about 300 C normal heating time would have caused the LIF element to begin to incandesce O, If this hypothesis were true, then the as the tenperature exceeded 400 C response of 5,120,000 represented the integral of incadescent light rather than a dose of 512 rad (the second largest dose in that batch of 647 ring badges from SONGS was 378 mrad). If the temperature of the element had been close to the melting point of 1,200 C for LiF, then perhaps some physical l change of the element would have occurred that would have caused the second f reading to be large. I have no knowledge whether this scenario happened, or could have happened, or would have caused a large residual if it did happen. My interest was to determine if a large residual could be produced by over heating a LiF element during the initial reading. The staff at Eberline was kind enough to perform the following ( experiment. Wey irradiated 40 LiF elenents to 10 rad from cesium-137. Wey then heated these elsnents in an oven (not in a TLD reader) at a

= - = 18 ( temperature of 600 t for 35 seconds. '!he normal heating sequence for an Eberline TLD reader 'is 250 % for le seconds using a hot finger. %e elements were then read in an Eberline reader using the normal heating sequence. h e responses were the same as the responses of unirradiated elements. B us, it appears that even if laser 'ILD reader had erroneously heated the element from ring badge no. 80365 to 600 %, the residual should have been closer to the normal value of about it or less, rather than the 11.5% observed. Eberline also provided me with some residuals that they observed for 4 very large doses of cobalt-60 delivered to LiF elenents. The l'. radiations were done by Battelle Pacific Northwest Laboratories at Eberline's request. he results showed the following residuals: { Dose (rad) Residual (%) j 1,000 1.0 10,000 9.4 20,000 3.5 40,000 6.8 80,000 13.9 100,000 14.3 %us, very large doses appear to be capable of producing residuals similar to the 11.5% residual observed for ring badge no. 80365, but not doses less ( than 10,000 rad. l Descrepancy Fran Previous Reports During my first visit to on December 18, 1986, one of their procedures for handling high-dose elements was described to me. My summary i j of their procedure is given on page 5 of my report to SONGS dated December I 11,1986 (revised January 7,1987): ( "If an element shows a dose larger than 15,000 mrad, procedures call for two actions to be taken. First, the elenent is ~

. ~. 19 read several times. If the response of the element continues to g p, decline with successive readings, this is a good indication that the initial large response was caused by ionizing radiation. If the response of the elenent does not decline, this indicates that the element is contaminated with a non-radioactive material that continues to burn with each reading. Second, the element is discarded." Unfortunately, did not follow this procedure with the element from ring badge no. 80365. %e element was read only once after the initial reading, and then it was discarded. During my second visit to on January 5,1987, I observed the responses of several high-dose elenents that were read several times. On page 8 of my report to SONGS dated January 7,1987, a typical sequence of repeated readings showed: Percent of Reading Response (nC) Reading #1 ( l 5,020,000 2 31,100 0.62% 4 3 39,200 0.78% 4 32,300 0.64% Wus, it appears that if a high-dose element is read several times, the response will not decline with successive readings as believes. It is unfortunate that the elernent from ring badge no. 80365 was not read several times, and it is even more unfortunate that the elenent was discarded by CONCLUSIONS There are only two facts that are known about ring badge no. 80365. i First, the initial response of the element from this ring badge was (. 5,120,063 nC. Second, the next reading of this element following a calibration irradiation to 350 mrad from Sr/Y-90 showed a residual of l i

20 (O Q 593,300 nc, about 11.5% of the initial response. Since discarded the element after the second reading, and since generates no specific data on loose elements, we have no other clues to interpret the initial response except for the usually large residual. I can identify three ways in which an unusually large residual can be produced. First, the element received a very large dose of ionizing radiation. Based on the cobalt-60 irradiations done for Eberline (80,000 rad minimum to cause a residual around 11.5%), and based on a typical conversion factor for gamma rays (10 nC/ rad), an element would have to show an initial response of about 800,000,000 nc to produce a residual of about 11.5%. However, the element from ring badge no. 80365 showed an initial response of only about 5,000,000 nC. This initial response appears to be f too small to cause an 11.5% residual. 1herefore, based on the data generated at during January and February, and based on the data provided by Eberline, I conclude that the 5,120,000 nC initial response of ring badge no. 80365 was not caused by ionizing radiation. A second way in which a large residual can be produced is if the TLD l reader malfunctions during the initial reading of an elenent and does not l anpty all of the electron traps (i.e., incomplete heating). The second reading of the element would reflect residual plus a portion of what should j have been the initial response of the element. If this is the cause of the large residual for ring badge no. 80365, then the malfunction occurred coincidentally when a high-dose element was being read. Since laser TLD reader was used to process 646 other ring badges from SONGS on l November 10, 1986 without a similar malfunction, I find this coincidence too ( much to accept. I doubt that a malfunction of the laser TLD reader caused the 11.5% residual. r, -,----,--e.-,m,-r r-~~nwv_ _,,----,w----,mwww-m ,gm.,,-w-r,,.., w, m - e n,, e,-rw w-w m---o- ,--v-

21 ( A third way in which a large residual can be produced is if the element were contaminated with a combustible material. This would cause a large initial response, and it could cause a large residual response if the contaminant were still present after the initial heating. Subsequent readings might have suggested the presence of a contaminant, and visual inspection of the element might have confirmed the presence of a contaminant. Unfortunately, discarded the element after the second reading. I believe the presence of a contaminant is the most reasonable explanation of the large initial and residual responses of ring badge no. 80365. 4 l l \\ \\ < O _ -. _ _..., _. _. _. ~. _, _ _ _ _ _ _ _ _ _.. _ -.. _..

6.6 m M I O V January 27, 1987 Dr. Phil Plato Phillip Plato, Inc. 1716 Ivywood Ann Arbor, MI 48103

Dear Dr. Plato:

We have elected not to read out the dosimeters accompanying your letter of January 26, 1987. management believes your test protocol is outside the scope of their agreement with Southern California Edison and we cannot at this time undertake further studies you request. Tests on nitrogen gas TLD heating can be duplicated at other sites. Since our management will be meeting with Mr. R. Warnock during the Health Physics Society Mid-Winter meeting, you might suggest they take it up again at that time. Sincerely, && JNS J annine MacDonald echnical Assistant Quality Assurance JMD/ leg Enclosure cc R. Warnock Southern California Edison O p --._-,.--.--,__----r - - " ' ' " = - ' ' - - " ' " - - - ' ' ' -

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A.5 P)RRp Plato, Inc. (- iFid typuesd* Aos Arter, Ansados ets January 28, 1987 Ma. Jeannine MacDonald Dear Jeannine Per a telephone agreement between Craig Yoder and Elisabeth Donnelly,1 as returning 7 of our original 11 groups of ring badges which we would like 1 you to process as part of the San Onofre overexposure study. Each group of dosimeters in within its own manilla envelope. These 7 groups are to be processed in one of two categories. Category It Read #1 in laser reader. Read #2 in laser reader. Irradiate to Sr/Y-90. Read #3 in laser reader. Group #1 consists of 16 doniseters which we would like read in the l laser reader. The numbers are 9037995 - 9037997 and 9037999 - 9038011. Please read Group 1 in the laser reader, then read them again in the laser reader to obtain the residual reading. For this group it is also necessary j to irradiate them to strontium / yttrium-90 and read them a third time in the ~ 1aser reader to obtain a correction factor for each chip. Group #3 consists of 24 dosimeters which should be read in the laser reader. Dosimeters 9038015 - 9038026, 9038032 - 9038042, and 9038045 should I be read in the laser reader, then read a second time for a residual reading. It is also necessary to irradiate thene dosimeters to strontium / yttrium-90 l to produce chip correction factors, and read them a third time in the laser reader. l Group #10 consists of six donimetern which will be read in the laner l reader. Donimatern 9038046 - 9038048 and 9038055 - 9038057 should be read l in the laser reader, and then read a second t:se in the laser reader for a residual reading. We need chip correction factors for thin group. 0 1 t

A.6 Category II: Read #1 in laser reader. Read #2 in laser reader. I Group #5 consists of nine dosimeters which will be read in the laser reader. Doniseters 9038030, 9038031, 8928247, 8928224, 8928225, 8928241, 8928226, 8928227, and 8928228 should be read in the laser reader and then l toad a second time in the laser reader for a residual reading. It is not necessary to produce chip correction factors for these stages. Group #7 cons tsts of nine dosiseters which will be read in the laser reader. Dosimeterr. 8928232 - 8928234, 8928238 - 8928240, and 8928244 - 8928246 should be read in the laser reader and then read a second time in the laser reader for a residual reading. No chip correction factors are 2 necessary for this group. Group #8 consists of nine dosisatern which should be read in the laser i reader. Domineters 9038058 - 3038063, 9038066, 9038073, and 9038078 should be read in the laser reader, and then read a second time in the laser reader j for a residual reading. No chip correction factors are necessary for this group. Finally, group fil should be read in the laser reader. Donineters 9038736 - 9038755 and 9038829 - 9038835 should be read in the laser reader then again in the laser reader for a residual reading. No chip correction factors are needed for these dosteeters. Please pend us the initial readings, teridual reading, correction factor readings, and the correction factors f or the groups as specified. The residual readings are very toportant in this study. Also, please send I i us the daily calibration factorn for both T1.D readern. Thank you for your help in reading these rings. Please call me at (313) 936-0762 or Phil Plato at (313) 764-0524 ff you have any questions. Sincerely yours, 3 Joseph A. Miklos l JAM ble l (0 i . ~.

( l APENDIX B Results reported by for the ring badges irradiated for this study. i i i i ' O i a-ww w

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