ML20236F505
| ML20236F505 | |
| Person / Time | |
|---|---|
| Site: | Millstone  |
| Issue date: | 06/25/1998 |
| From: | Hagan D, Marcello J, Turner I NORTHEAST NUCLEAR ENERGY CO. |
| To: | |
| Shared Package | |
| ML20236F499 | List: |
| References | |
| CR-#-M2-98-1533, CR-#-M2-98-1533-R01, CR-#-M2-98-1533-R1, NUDOCS 9807020190 | |
| Download: ML20236F505 (22) | |
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Docket No. 50-336 B17356 Attachment 2 Millstone Unit No. 2 Event Review Team Report Root Cause Investigation UGS Personnel Contamination Event J
June 1998 k
9807020190 990630 .
'Northecat Utilities System EVENT REVIEW TEAM REPORT ROOT CAUSE INVESTIGATION UGS PERSONNEL CONTAMINATION EVENT CR # M2-98-1533 Revision 1 Team Members: ,
4-Daniel A. Hagan - Lead Date
- h. b J. Mardello - U2 CA Department Date GbdW J
/M tra M. Tu er 3 Health Physics Date Reviewed By: ~
. MAYF Steve H Jrd, Manager C'A ' Date i Approved By: TrC 649N
{ Jarrlen A. Price, Director Unit 2 Date PORC Review: J^ 6[2k9d bate PORC No.: # ' /03
i o UGS Personnel Contamination Event CR # M2-98-1533 EXECUTIVE
SUMMARY
On May 23,1998, two maintenance mechanics became contaminated while removing ,
the upper guide structure (UGS) from the reactor vessel. The mechanics were decontaminated I and released by IIcalth Physics. Nuclear Oversight personnel began an investigation into the event on Tuesday, May 26th. By Thursday, discussions between Ifealth Physics management and Nuclear Oversight reached an impasse. A Condition Report (CR M2-98-1533) was submitted specifying four issues: two violations of 10CFR20, one procedure violation, and an inadequate radiological survey On June 5th, an Event Review Team (ER'O was formed to investigate this event. Based upon the review of the ERT, six conditions adverse to quality and eight areas of improvement have been identined. The adverse conditions are:
- 1) Failure to comply with 10CFR20 regarding radiological surveys;
- 2) Poor work relationship between Unit 2 Health Physics and Nuclear Oversight;. l
- 3) Lack of an appropriate response by Unit 2 Health Physics management to issues ' l identined by Nuclear Oversight;
- 4) Radiation Work Permit violation regarding the failure to implement a procedure;
- 5) Delay in performing an initial whole body count;
- 6) Inadequate procedures and practices associated with facial contamination and whole body counting.
The causes of the event are:
- 1) HP Management Standards and Expectations Errors inadequate Supervision / Lack of Technical Knowledge and Skills.
Minimal Comm.unication of Expectations
- 2) Non-Conservative Decision Making
- 3) ProceduralNon-compliance
- 4) Non-Questioning Attitude Routine radiological work should not be affected by these causes. Selected corrective j actions should be implemented prior to performing radiological significant work or work with )
signincant radiological potential.
l Unit I and Unit 3 Ilealth Physics programs and practices were reviewed relative to this event and no conditions adverse to quality were identified. The above conditions are specific to Unit 2 Ilealth Physics. There are areas for improvement; several of those areas for improvement l identified apply to all three Millstone units.
The event at Connecticut Yankee (CY) on November 2,1996, involving entry into the transfer cam.1 and the immediate corrective actions was compared to this event. Some of the ;
common themes identified include: the lack of an appropriate initial response by Unit 2 Health l Physics management to identified adverse conditions, need for improvements in the air sampling program, and failure to recognize the potential radiological significance of alpha contamination.
Other issues were identified as well and are presented in this report. Due to the differing work area conditions, the potential risk to Millstone personnel is several orders of magnitudes below the risk involved in the CY event.
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Event Review Team Report, Rev 1. 2 June 23,1998
l 1 , .,
. UGS Personnel Contamination Event !
CR # M2-98-1533 1
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INTRODUCTION l Event
Description:
On Saturday, May 23,1998, Unit 2 personnel were continuing with reactor disassembly activities. The reactor head had been removed at 1000 hours0.0116 days <br />0.278 hours <br />0.00165 weeks <br />3.805e-4 months <br />. Operations had flooded the reactor cavity to above thirty-one feet in preparation for removal of the upper guide structure (UGS). At the beginning of second shift, Maintenance and IIealth Physics supervisors performed a pre-job brief with personnel involved in the removal of the UGS. At 1930, Maintenance and liealth Physics personnel entered the radiologically controlled area and commenced work.
From 1930 to 2330, Maintenance and llealth Physics personnel lifted the UGS lift rig from the north saddle onto the UGS, installed the lift rig, raised and cribbed the ICI plate, and transferred the UGS from the reactor vessel into the north saddle.
Upon exit from the containment, two maintenance mechanics alarmed the 38'6" PCM-1 whole body frisker. They were escorted to the health physics l'acility for additional surveys. Both mechanics were found to have 400 to 500 corrected counts per minutes (ccpm) facial contamination. The workers were decontaminated to less than l
100 ccpm and passed the radiological control area exit PCM-1 satisfactorily. The on-shift licalth Physics technician attempted to have a whole body count perfonned on the two maintenance workers. No one on-site, however, was qualified to operate the whole body counting equipment. The Ilealth Physics Manager was contacted and authorized j the release of the workers contingent on a whole body count being performed on May 26,1998. At this time, the workers left site for the remainder of the long weekend.
On Tuesday, May 26th, the two workers returned to work and received a whole body count. The whole body count results for Worker #1 indicated no detectable activity; the report for Worker #2 indicated 5.29 nanocuries of Cobalt-60.
The contamination events were discussed at the Tuesday, May 26th, management morning meeting. Following the meeting, Nuclear Oversight personnel I began an investigation of the event. Documents were obtained, reviewed, and several issues were identified. Numerous discussions between Health Physics and Nuclear Oversight personnel ensued on Tuesday, Wednesday, and Thursday. By Thursday afternoon, discussions reached an impasse. At 1600, Nuclear Oversight delivered Condition Report M2-98-1533 to the Unit 2 Control Room.
An Event Review Team was formed on Thursday, June 4th, and began
- investigation on the 5th.
1 SCDpc:
l The Event Review Team (ERT) was formed to complete the following tasks:
- 1. Review the actions and issues associated with two personnel contamination events I which occurred in Unit 2 Containment during the removal of the Upper Guide Structure.
- 2. Compare and contrast these actions and issues to procedural requirements, 1 regulatory requirements, and current station and industry standards.
l 3. Evaluate overall effectiveness of associated procedures and programs.
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l Event Review Team Report, Rev 1. 3 l June 23,1998 u
o UGS Personnel Contamination Event CR # M2-98-1533 Compare and contrast the actions and issues to those from the Connecticut Yankee 4.
Transfer Canal event of November 2,1996.
- 5. Review station response to similar events and determine the extent of the condition.
- 6. Review and evaluate Unit 2 Health Physics management and Nuclear Oversight response to the event.
Time Line:
Saturday May 23, Reactor head removed, cavity posted Technical Specifications Locked 1998 liigh Radiation Area.
1000 1800-1900 Pre-job brief for UGS removal. Radiological, Foreign Material Exclusion Area, work evolution, and industrial safety issues discussed. All IIcalth Physics technicians and workers for job in attendance.
1930-2330 UGS removal commenced. Workers exit work area, and contamination was noted by llealth Physics.
2330-0000 Workers skin decontamination.
Sunday May 24,1998 Unit 2 Radiation Protection Manager (RPM) notified of facial 0000 contamination. Delay in whole body count (WBC) authorized by RPM.
Tuesday May 26,1998 Worker #1 completes 3 minute WBC.
0700 0900 Nuclear Oversight representative commences review of facial contamination events.
1935 Worker #2 completes 3 minute WBC.
Thursday May 28,1998 Meeting with U2 IIealth Physics Manager, Radiation Protection 1330 Supervisor, and Oversight representatives.
1600 Condition Report M2-98-1533 describing Oversight identified conditions adverse to quality issued.
Thursday June 4,1998 Event Review Team formed to assess CR M2-98-1533 items.
Friday June 5,1998 Event Review Team convened.
0930 1
Event Review Team Report, Rev 1. 4 June 23,1998
. UGS Personnel Contamination Event CR # M2-98-1533 PROBLEMS, ANALYSIS, & SIGNIFICANCE Conditions Adverse To Ouality:
- 1. Radiological Surveys:
Regulations require surveys to be performed that are necessary and reasonable to evaluate the extent of radiation levels, the concentrations of radioactive material, and the potential of the radiological hazards that could be present. Completed surveys are required to be documented.
10CFR20, Subpart F - Surveys and Monitoring,61501 " General" states:
(a) Each licensee shall make or cause to be made, surveys that (a)(1) May be necessary for the licensee to comply with the regulations in this part; and (a)(2) Are reasonable under the circumstances to evaluate-(a)(2)(i) ne extent of radiation levels; and (a)(2)(ii) Concentrations or quantities of radioactive material; and b (a)(2)(iii) He potential radiological hazards that could be present.
Evaluation of infonnation related to the event showed that the survey used to conduct the work on the UGS lift rig work platform is dated April 27,1998. At that time, the work platform was in the north saddle and was dry. Prior to work on May 23rd, the reactor cavity water level was raised to above thirty one feet. To raise the cavity level, water flowed from the RWST through the ECCS and the RCS into the reactor vessel. Thus, the potential existed for a change in the radiological conditions on the work platform. This change could have materialized as a shift in radioactive contamination levels or the presence of hot particles, as a result of the cavity flooding. Surveys performed by licalth Physics prior to maintenance workers accessing the work platform consisted of a scan of the area with a teletector. This is not regarded as an adequate survey for detection of the potential changes in the radiological conditions. The ERT believes this to be a violation of 10CFR20.1501, 10CFR20.2103 " Records of surveys" states:
(a) Each licensee shall maintain records showing the results of surveys and calibrations required by 20.1501 and 20.1906(b). The licensee shall retain these records for 3 years after the record is made.
Based on interviews with the mechanics and Health Physics technicians covering the UGS removal, surveys were performed on the UGS lift rig and the ICI plate lift rig as they were removed from the water. Surveys of the work platform were also performed as the ICI plate was lifted and cribbed. Additionally, a post decontamination survey of the UGS upper tripod area was conducted. None of these surveys, however, were documented. The ERT believes this to be a violation of 10CFR20.2103.
The above conditions reflect the potential regulatory violations identified.
Event Review Team Report, Rev 1. 5 June 23,1998 i
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. UGS Personnel Contamination Event CR # M2-98-1533
- 2. Unit 2 HP Management and Nuclear Oversight Relationship:
During ERT interviews, it became apparent that an ongoing, unhealthy j relationship between Unit 2 Health Physics management and Nuclear Oversight has developed. The relationship has become strained and tense, and may be construed to involve harassment and intimidation. This relationship materialized as a result of an overly defensive attitude by Health Physics to input from Nuclear Oversight.
' 3. Inappropriate response from Unit 2 HP Management:
On Tuesday, May 26th, Nuclear Oversight learned of the May 23rd facial contamination of the two maintenance workers and began an investigation. On Tuesday, Wednesday, and Thursday, Oversight personnel reviewed documents provided by Unit 2 Health Physics and discussed potential issues with the Health Physics Manager and Radiation Protection Supervisor. Discussions between liealth Physics and Oversight personnel could not resolve the issues and an impasse was reached. Health Physics personnel did not believe any of the identified issues were problems. Ilealth Physics personnel performed no self-assessment to validate their assumptions and did not initiate any corrective actions. Corrective actions taken to date have been due to requests from the ERT.
- 4. Radiation Work Permit non-compliance:
RWP# 98-0048 Job Step 3 requires workers to comply with RPM 2.5.2
" Guidelines for, Spent Fuel Pool or Flooded Reactor Cavity Work." Step 1.1.1 of this procedure states: " REVIEW radiological consideration for work activity and work area and SPECIFY survey requirements and frequencies for the following:
- Alpha contamination e Alpha airbome radioactivity
. . Tritium Monitoring
)
e 'llot Particle Monitoring."
There was no evidence that the required review was conducted. No requirements for surveillance of the above items was specified to personnel involved in the task.
' 5. Delay in performing an initial Whole Body Count:
RPM 1.3.12, " Internal Monitorin'g Program" does not specify a time frame in which to administer a whole body count after a facial contamination has been identified. Management expectations established at Units 1,' Unit 3, Connecticut Yankee, and Seabrook require completion as soon as possible (maximum period within twenty four hours). Such expectations are based upon biological clearance of radiological contaminants once taken into the body. Thus, the ability to assess dose is dependent upon collection of data within a relatively short period of time.
These was a delay of sixty-seven hours between the time one of the individuals became contaminated, and the time he received a whole body count. The delay for the second contaminated individual was filly five hours. The individual who was delayed sixty seven hours showed no contamination, while the individual who was
. delay fifty five hours showed a minimal quantity of Colbalt-60.
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' Event Review Team Report, Rev 1. 6 l June 23,1998
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UGS Personnel Cont: min: tion Event CR # M2-98-1533 The delayjeopardized the ability to collect needed dose assessment information.
This has challenged the ability to calculate an accurate estimate of internal dose.
The delay was due to an exercise of management discretion permitted by existing procedures. In light of departmental knowledge of prior events of similar character (CY), this decision is considered to be below industry standards.
- 6. Facial Contamination and Whole Body Counting:
RPM 1.3.12, Rev. 3, " Internal Monitoring Program" step 1.1.8 requires a non-routine whole body count when, among other possibilities, "An unanticipated facial or nasal contamination is discovered."
Review of contamination reports revealed two instances of facial contamination addressed by Unit 2 Ilealth Physics where whole body counts were not administered as required. This is considered to be in non-compliance with existing procedures.
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Note: The above conditions adverse to quality will be tracked via Action Requests linked to CR #M2-98-1533.
Areas For Improvement:
- 1. Alpha frisking requirements for personnel contamination and loose surface contamination surveys are not clear in the Radiation Protection Manual (RPM).
RPM 2.11.1, Rev. 2 " Surveys and Decontamination of Personnel and Clothing" and RPM 2.2.2, Rev. 2, " Contamination Surveys" provide instructions on surveys for alpha contamination but do not provide specific criteria that would initiate an alpha contamination survey.
- 2. Requirements and expectations for initiation of breathing zone air samples is not established.
While not explicitly required by procedure or regulation, it is desirable to use breathing zone air samples in work areas with the potential of airborne radioactivity.
Minimal procedural guidance was noted in this area. During interviews with station personnel, it was determined that breathing zone air sampling is infrequently used at Millstone. Unit 2 Health Physics, for example, has taken only one breathing zone air sample in the last six months. Department personnel instead have chosen to take work site (general area) air samples. Breathing zone air sample data are considered useful for implementation of ALARA programs and should be investigated.
- 3. Documentation of activities During review of the event, it became apparent that many activities are poorly documented. Some records are required to be kept pursuant to regulation, others are required by procedure, or needed in the event of civil liability. Aside from completion of surveys, which has regulatory implications and has been discussed above, some instances of documentation inadequacies included: decisions made regarding implementation of engineering controls, technical bases (e.g. isotopic Event Review Team Report, Rev 1. 7 June 23,1998 L_.___._ _ _ _ _ _ _ . . _ _ _
, UGS Personnel Contamination Event
! CR # M2-98-1533 i
characterizations), and the use of management discretion.
Documentation inadequacies included missing records, incomplete records, and unsigned records.
- 4. Unit 2 Ilealth Physics Awareness of Alpha Contamination Significance The presence of alpha emitting radionuclides in contamination can greatly increase radiological risk to workers. This contamination is difficult to characterize, and requires completion of offsite analyses. As a result, a conservative nuclide has been selected to provide for practical control of alpha contamination During conversations with the Health Physics staff at Unit 2, it became apparent that the significance of risks associated with alpha contamination is considered to be low. Examples of the low concern for alpha contamination include: alpha frisking was not performed on the contaminated workers, no current alpha isotopic characterization of work areas, and a review of the risk from alpha contamination omitted from the pre-job briefing.
- 5. Confirmatory Monitoring Program Confirmatory Monitoring describes the process of using data collected from whole body counts for confirmation of adequate program controls. Although this is not described in procedure, this process is considered to be an industry accepted practice. The process requires whole body counting of selected individuals, and review of the resulting data against their program activities. All three Millstone l units have a Confirmatory Monitoring program established.
At Unit 2, no confirmatory monitoring has been performed in the last several months.
- 6. Control and Quality of the Radiation Protection Manual The Radiation Protection Manual (RPM) contains the instructions . for implementation of the radiation protection program at Millstone Station. Originally, this procedure set was designed for implementation by one department. When the Health Physics Department was divided into the current five departments, control over procedure content, review, and approval was drawn to a minimum. As a result, personnel modifying procedures have been compelled to include only minimal standards and minimum specific requirements. This has allowed procedures to evolve that are non-specific and require extensive evaluation and judgment in the field. The ERT believes more specific requirements should be included in the RPM.
- 7. Communications among Health Physics Technicians A review of the work evolution showed that communication of radiological
' information among personnel was poor. Health Physics personnel maintained l varying perspectives regarding the actual radiological controls in place at the time of the event. For example, the two HP technicians on the Containment 38'6" had different understanding of the actual radiological posting.
- 8. IIP Tech specific pre-job briefings !
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Event Review Team Report, Rev 1. 8 June 23,1998 9
UGS Personnel Contamination Event CR # M2-98-1533 The pre-job brief for this event was focused on the maintenance personnel and the maintenance activitics. Maintenance supervision performed a detailed review of the procedures for removing the UGS, lifting the ICI Plate, and lieavy Loads.
During the same meeting, Health Physics supervision performed a briefing for the maintenance personnel on the work area conditions and radiological controls for the job. At no time, however, were the IIealth Physics technicians briefed on expectations for their specific activities during thejob.
Event Review Team Report, Rev 1. 9 June 23,1998
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i o' . UGS Personnel Contamination Event CR # M2-98-1533 CAUSES OF THE EVENT
- 1. Health Physics Management Standards and Expectations Errors:
- a. Inadequate Supervision / Lack of Technical Knowledge ar>d Skills.
The ERT has concluded that the Health Physics Department at Unit 2 is currently being inadequately managed and supervised. This conclusion is based upon many factors: interviews with personnel, radiological control area access logs, knowledge of radiological work, knowledge of radiological risk, and inappropriate response to potentially significant events.
- b. Minimal Communication of Expectations The ERT has concluded that management expectations are poorlfideritified, poorly communicated, and not commensurate with control r.ecessary for mitigation of radiological risk. Unknown or unclear expectations have led to excessive use of discretion by personnel.
- 2. Non-Conservative Decision Makina- ;
The ERT recognized that all licalth Physics department staff interviewed were of the opinion that the potential significance of the event was low. As a result, no corrective actions or investigations were taken by the department's own initiative.
Procedures were interpreted to support this position, and reflected non-conservative decision making.
- 3. Procedural Non-comoliance:
The ERT has documented several examples where personnel did not comply-with the procedures. It is considered that procedure non-compliance aggravated the
= significance of this event.
4.Non-Questioning Attitude:
The ERT believes that a less than adequate questioning attitude was exhibited by department personnel. This attitude preempts the self assessment process and self improvement.
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Event Review Team Report, Rev 1. 10 .!
June 23,1998 t ,
J' UGS Personnel Contamination Event CR # M2-98-1533 GENERIC IMPLICATIONS Millstone Station:
Interviews were conducted with the Unit 1 Radiation Protection Manager and the Unit 3 Radiation Protection Manager. The preliminary conditions adverse to quality and areas for improvement were discussed. As appropriate, Unit I and Unit 3 documents were reviewed to validate information. The ERT concluded that the adverse conditions do not affect Unit 1 or Unit 3 Health Physics Departments. Procedural inadequacies, which are identified as Areas for Improvement, are generic to all three departments.
Connecticut Yankee:
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! The following comparison was developed from a review of the November 2,' 199'6, CY Transfer Canal Event Report written by the Independent Review Team (IRT). The first column represents items taken from the Health Physics Department section of the IRT report (section 4.1). The second column represents the status of the counterpart Unit 2 liealth Physics program, as related to this event. The third column is a synopsis of Event Review Team sentiment on the present investigation. Items presented in bold are considered to reflect similarities between the two programs. Items in bold and italics are considered to represent program issues unique to this event.
Conclusion from CY report U2 HP Event Comparison / Conclusion
dose controls ALARA review.
- 2. Work scope was not RWP required adherence to RPM Work completed was not in coincident with RWP. procedure 2.5.2, which provides conformity with the instructions for work in the requirements of the RWP.
cavity areas. Terms of this procedure were not met in full.
!- contributed to confusion in work requirements. regarding administrative controls l~ control. (RWP).
l 4. Failure to control RWP No changes were made to RWPs Work control requirements administration was a breakdown during pcocess. remained static.
of system.
- 5. Workers knowledge of RWP Workers demonstrated increased awreeness of RWP requirements was low / awareness of RWP requirements requirements demonstrated l Personnel do not review RWPs / general practice of RWP through interviews and )
}. in practice. administration not reviewed. demonstration of good radiation L ,worker practices.
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Event Review Team Report, Rev 1. I1 June 23,1998 i
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. UGS Personnel Contamination Event CR # M2-98-1533 l Conclusion from CY report l U2 HP Event Comparison / Conclusion i 6. AWO incorrectly identified AWO did not identify RWP. Worker must contact HP to I R W P. obtain RWP information.
l 7. Confusion about cleanliness HP demonstrated poor awareness Plant conditions dissimilar, but l and risk. Worker's concern at a of risk associated with alpha HP awareness of risk minimum due to perspective of contamination. associated with alpha l HP. contamination similar.
l 8. RWP requires complete
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MT supervision content with MT supervision did not believe briefing. MT did net get info briefing. Satisfied info provided their briefing to be inadequate.
they knew they needed, was comprehensive.
- 9. RWP requires complete Most recent alpha contamination HP did not address allitems of briefing. HP did not provide all survey data and associated risk radiological significance at pre-info needed. not discussed. Job briefing.
- 10. Instructions did not Personnel onjob content with Personnel believed their briefing adequately address risk from briefing. to be adequatel I worker's point of view.
I1. Survey data is not readily Survey data is available for the Work force may obtain l available for the work force. work force. radiological information without the assistance of HP.
- 12. Internal dose was not Internal dose was not included in Need to perform TEDE ALARA included in the needs ALARA review, is subjective. No inhalation was determination for actuation of an anticipated by the staff. The ALARA review. possibility ofingestion was not considered, however.
- 13. Job leaders determine need RPM 5.2.3 requires ALARA Not noted to be an issue. . l for an ALARA review. Coordinator to determine need ALARA review was completed for an ALARA review. for overalljob.
- 14. Use of respirators not Evaluation of engineering Supervision did not believe j properly evaluated and controls was not documented. engineering controls were documented, due to work necessary so documentation not constraints. required by ALARA review.
- 15. Contamination had not been Survey data invalidated by Potential radiological hazards characterized for work area. submersion of work area. in the work area were not Subsequent survey not adequate adequately characterized.
or documented.
- 16. Isotopic data in analysis Isotopic data not reviewed prior Actual significance of alpha stage not collected and reviewed to work evolution. emitting nuclides in mix for significance. unknown. Historical knowledge relied upon.
- 17. Air sampling at start ofjob Air samples were not in Air sample data oflimited does not provide useful data for immediate vicinity of work, were value for determination of work control. Samples were not not representative of breathing dose.
representative of breathing zone. zone.
- 18. Confusion regarding age of Survey data relied upon for work Potential for change in survey caused reliance on area potentially obsolete due to radiological conditions not inadequate data. work area being submersed. adequately characterized.
Event Review Team Report, Rev 1. 12 June 23,1998
UGS Personnel Contamination Event CR # M2-98-1533 Conclusion from CY repon U2 HP Event Comparison / Conclusion
- 19. Confirmatory monitoring Confirmatory monitoring data Need for improvement in air may be used to ensure minimal, not analyzed for sampling practices not representative air sampling, not significance. identified (via confirmatory in use at time. monitoring or other means).
- 20. Poct radiological work Workers selected for task in part Radiological work habits taken practices exhibited by workers. for good radiological work into consideration.
practices.
- 21. HP personnel did not HF personnel were in multiple llP personnel were assigned maintain requisite level of locations controlling work. exclusively to task.
control overjob.
- 22. Communications between HP Communications between HP Poor communications lead to personnel were poor regarding personnel coveringjob were poor poor coordination of coordination of engineering as differing opinions were knowledge and actions related controls. identified regarding work to radiological,I risk.
processes.
- 23. HP management was not HP management was not This included initiation ofin-responsive in the collection of responsive in the collection of vitro bioassay methods.
critical dose assessment data. critical dose assessment data.
- 24. Poor management did not Management did not mitigate No selfinitiated compensatory mitigate possibility of over consequence of the event. actions were noted.
exposure.
- 25. Once dose assessment was Bioassay was not initiated in Need to collect bioassay data not determined to be appropriate, time to collect valuable data. Not recognized bypersonnel.
good decisions were made. apparent to organization as dose assessment commenced late in process.
- 26. Management of records does Records are retrievable, and No problems noted with not support intended purpose. available for review. availability of completed records.
- 27. Excessive number of Two teams (ERT and outside No substantial problems evaluators impedes conduct of consultant) investigating. identified with the level of business. review. One suggestion for info points of contact adopted. _
Seabrook:
Based on an interview with the Seabrook Radiation Protection Manager:
. WBC is required for facial contamination.
. alpha contamination is characterized and is not a significant problem at the Station e the use of breathing zone air sampling is increasing Event Review Team Report, Rev 1. 13 June 23,1998
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, UGS Personnel Contamination Event CR # M2-98-1533 CORRECTIVE ACTION RECOMMENDATIONS Remedial Actions:
No remedial actions were taken by Unit 2 liealth Physics Department personnel.
[.
Comnencatorv Actions:
The ERT recommended the following compensatory actions be taken:
- 1. Survey all hard hat chin straps used in the Containment 38'6" Foreign i
Material Exclusion Area, l During interviews on the afternoon of June 5th ~ with the two Maintenance mechanics, it was determined to be reasonable that the skin contamination events could have resulted from the hard hat chin straps used 1 in the Containment 38'6" FME Area. Health Physics was immediately requested to survey all chin straps in the area and to inform the ERT of the i
results. Surveys were performed in the evening of June 5th. Two p contaminated chin straps were identified.
- 2. Perform gamma / alpha spectroscopy of UGS work platform contamination.
The latest gamma and alpha spectroscopy data is four years old. Due to the extended shutdown, these values may no longer representative of current conditions. Accurate, up-to-date data _ is essential to ensure correct ratios are being used for calculating threshold values for initiating alpha counting and surveys.
- 3. Perform an internal dose assessment of the two contaminated mechanics.
t The whole body counts for these two individuals were delayed for approximately sixty hours. No internal dose assessment was performed.
- Although the lack of an initial whole body count challenges the ability to perform an accurate dose evaluation, using conservative values (i.e. worker cleared the PCM and protected area portal monitors) will provide a reasonable estimate of internal dose.
- 4. Review all ALARA Reviews to ensure current standards are being satisfied.
Due to delays in performing physical work activities, some ALARA
- Reviews are more than eighteen months old. These should be reviewed to ensure current standards and expectations are being satisfied.
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j Event Review Team Report, Rev 1, 14 .!
June 23,1998 -
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.~ UGS Personnel Cont:.mination Event CR # M2-98-1533
- Corrective Action To Prevent Recurrence:
l 'l. Radiological Surveys:
Unit 2 senior management should evaluate the technical knowledge and expertise of Health Physics Management using recognized industry standards and take corrective actions as necessary to ensure adequate technical knowledge--
- i. and expertise is in the department to support safe conduct of work within the l
Radiologically Controlled Area. (cause 1.a and 1.b) l Unit 2 senior management should set standards for Health Physics management for monitoring and evaluating in-plant work activities. These standards should I include a minimum of four formal work observations per manager and l supervisor per month and a minimum of one entry per day . into the Radiologically Controlled Area to monitor work and plant conditions. (cause 1.a and 1.b)-
Health Physics management should review the threshold for initiation and conduct of surveys, completion of documentation, and assurance of adequate record keeping. Reasonable standards consistent with the regulations and licensing bases should be adopted and committed to by the department. (cause 1.b)
- 2. Delay in performing an initial Whole Body Count:
Revise RPM 1.3.12 " Internal Monitoring" to include the requirement that a whole body count shall be administered for facial contamination within twenty four hours of the intake. (cause 2 and 4)
Revise staffing assignments to ensure's whole body counting equipment operator is on-site or on-call at all times. (cause 3)
. Provide the Health Physics Manager and Supervision with the necessary internal
! dose assessment training that is required to make the right decision when assessing for internal dose. (cause 1.a)
L Health Physics Manager should review and -adopt Senior Management's expectations with regard to conservative decision making. (cause 2) >
- 3. Facial Contamination and Whole Body Counting:
Review and disposition'all prior contamination events as appropriate. Evaluate l for potential internal dose as necessary. (cause 3)
Develop procedural instructions that will require collection of appropriate data for facial contamination events. (cause 2 and 4)
Event Review Team Report, Rev 1. 15 J t June 23,1998 l -
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.." UGS Personnel Contamination Event CR # M2-98-1533 1
Corrective Action:
- 1. Unit 2 HP Management and Nuclear Oversight Relationship:
This issue has been assigned to the Safety Conscious Work Environment Group to facilitate.
- 2. Inappropriate response from Unit 2 Health Physics Management Unit 2 senior management should re-emphasize standaals and expectations regarding response to Oversight input and issues. (cause 2 a.<d 4)
- 3. Radiation Work Permit non-compliance:
' Radiation Work Permits should be reviewed for appropriate content. Review should include ~ evaluation and inclusion of appropriate controls; and consideration of the benefit of referencing external documents. (cause 3) llealth Physics Manager should re-emphasize the importance of following procedures and complying with RWPs. (cause 3)
Areas For Improvement Corrective Actions:
- 1. Alpha frisking requirements for personnel contamination and loose surface contamination surveys are not clear in the Radiation Protection Manual (RPM).
Revise RPM 2.11.1 and RPM 2.2.2 to provide comprehensive instructions with appropriate threshold . values' for performing alpha surveys on personnel contamination events and for loose surface contamination. (cause 3)
Ensure a procedural process is established to characterize alpha contamination.
The results of this analysis should be used to revise alpha survey threshold calculations and supplement HP technician training. (cause 3)
. 2. JAir sampling program does not include breathing zone air sample expectations and requirements.
4- Revise RPM 2.2.4 " Portable Particulate, lodine, Tritium, and Noble Gas Sampling" to provide guidance on when to take a breathing zone air sample.
Conduct assessments of the air sampling program and incorporate improvements as necessary and reasonable. (cause 3)
- 3. Documentation of activities It is recommended that the department review existing records, improve existing documentation by establishing clear standards and expectations, and performing accordingly. An evaluation should be completed to identify the l . .
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, UGS Personnel Contamination Event CR # M2-98-1533 records required and those desired to describe program activities, and a method developed to attain such goals.
- 4. Unit 2 Ilealth Physics awareness of alpha contamination significance It is recommended that the licalth Physics Department review the significance of alpha contamination as it pertains to radiological risk (dose),
existing plant conditions, and protective measures. Methods for adjustment in program controls should be developed to provide for control of risk in changing conditions. (cause 2 and 4)
- 5. Confirmatory Monitoring Program 4
It is recommended that the llealth Physics Department review the role of a confirmatory monitoring program, developed programs, and incorporate improvements into the conduct of radiation protecdon activities. (cause 2 and 4)
- 6. Control and Quality of the Radiation Protection Manual It is recommended that station senior management designate one individual with responsibility and accountability for maintaining quality and control of -
the RPM. Based on current ilP program status, it is suggested that the Unit 3 Health Physics Manager be given this responsibility. (cause 3) ,
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- 7. Communications among licalth Physics Technicians Consider sending entire department to communication training. The IIcalth Physics management should reinforce expectations that people must work together for work to be ' completed successfully.
- 8. IIcalth Physics Technician Pre-Job Briefings j
It is recommended that the 11ealth Physics Department adopt the practice of l providing specialized plans and briefings for radiologically significant' work - l evolution's. Such planning should reflect regulatory guidance and ;
progressive industry practice as practicable. (cause 1.a,1.b,2,3, and 4)-
i Event Review Team Report, Rev 1. 17 June 23,1998 ;
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,[' ' UGS Personnel Contamination Event CR # M2-98-1533 ADDITIONAL INFORMATION Limit Significant Radiological Work:
Throughout the investigation, the ERT discovered numerous examples ofinadequate supervision, lack of technical knowledge and skill, non-conservative decision making, and a non-questioning attitude. The negative impact of these issues on quality is further aggravated by the poor relationship with Nuclear Oversight. The ERT recommends that radiologically significant work (high dose rates and/or high contamination) or work with significant radiological potential be placed on hold until such time that Unit 2 management is assured the following issues are resolved:
- 1. The Unit 2 Director ensures adequate technical knowledge and expenise exist in the Health Physics department to properly assess and control significant radiological
~
work.
- 2. The relationship between the Unit 2 health Physics department and Nuclear Oversight is healthy.
- 3. HP management establishes a process to ensure HP technician pre-job briefs are conducted and include clear, concise standards and expectations that comply with procedural requirements and regulations.
4 The monitoring and enforcement of standards and expectations by HP management meets Unit 2 senior management expectations.
5.' A questioning, conservative work attitude and environment is established in Unit 2
~ HP.
Good Practices Identified:
Based on interviews and a review of documents, the following good work practices have been identified:
- 1. The pre-job brief performed by the Unit 2 Maintenance supervisors was exceptional.
- The information was accurate and complete. All maintenance workers attended; this was documented in the Automated Work Order for the job. The procedures for
' lifting the UGS and the ICI Plate were reviewed in detail. The Heavy Load
< . procedure was also reviewed. Time was taken for questions, answers, and further clarification. Foreign Material Area requirements were explained along with -
industrial safety requirements.
- 2. Procedure compliance by Maintenance personnel was excellent. The Maintenance supervisor was on the Containment 38'6" with the procedure and watching work activities via a remote camera. Each step was directed by the supervisor. ' As each q 1
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p
. UGS Personnel Contamination Event CR # M2-98-1533 step was performed, the supervisor confirm performance via the monitor and checked off the procedure step as completed.
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l Event Review Team Report, Rev 1. 19 June 23,1998
[' UGS Personnel Contamination Event CR # M2-98-1533 PERSONNEL INVOLVED Personnel Interviewed:
Maintenance:
Dave Buscetto, U2 MT Supervisor Scott Getman, Upgrade Mechanic Brian Stangle, MT Electrician Stu Roberts, MT Mechanic Ilealth Physics:
Andy Vomastek, UI Radiation Protection Manager Maria Nappi, U2 Radiation Protection Manager Robert Decensi, U3 Radiation Protection Manager Don Delcore Jr., U2 Upgrade Radiation Protection Supervisor Mitchell Callahan, U2 Radiation Engineering Supervisor Phil Calandra, U2 ALARA Coordinator Jan Drzewianowski, IIP Technician Joel L'Ileureux, lip Technician Sandi Dagata, HP Technician Paul Meizzies, IIP Technician Paul MacDonald, IIP Technician Nuclear Oversight: ,
Tom Stafford, Nuclear Oversight Luke Bozek, Nuclear Oversight Industry Contacts:
Bill Cash,' Seabrook Radiation Protection Manager Jay Tarzia, CY Assistant HP Manager 1
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1 Event Review Team Report, Rev 1. 20 June 23,1998
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- . J'. o * . UGS Personnel Contamination Event CR # M2-98-1533 REFERENCES CR # M2-98-1522 ' Nuclear Oversight Health Physics Findings".
RPM 1.1.1 " Health Physics Program, Organization, and Responsibility of Key Personnel".
RPM 13.12 " Internal Dose Program".
RPM 13.13 " Bioassay Sampling and Development".
RPM 13.14 " Personnel Dose Calculations and Assessments". .
RPM 1.5.5 " Guidelines for the Performance of Radiological Surveys".
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RPM 2.1.1 " Issuance and Controls of Radiation Work Permits (RWPs)".
RPM 2.1.2 "ALARA Interface with RWP Process".
.. RPM 2.2.2 " Contamination Surveys".
RPM 2.2.4 " Portable Particulate, lodine, Tritium, and Noble Gas Sampling". .
RPM 2.4.1 " Posting of the Radiological Controlled Area (RCA)". I RPM 2.5.2 " Guidelines for Spent Fuel Pool, and Flooded Reactor Cavity Work".
RPM 2.11.1 " Survey, Decontamination of Personnel and Clothing". !
ERT Documents: !
During the investigation of this event, many unique documents were assembled and reviewed. Additionally, many regulatory and station documents were reviewed. ne l ERT maintained a file of all unique documents and most regulatory or station !
documents.
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l Event Review Team Report, Rev 1. 21 June 23,1998