ML20236Q166
| ML20236Q166 | |
| Person / Time | |
|---|---|
| Site: | Crystal River  |
| Issue date: | 11/16/1987 |
| From: | Hosey C, Weddington R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| To: | |
| Shared Package | |
| ML20236Q146 | List: |
| References | |
| 50-302-87-35, NUDOCS 8711190220 | |
| Download: ML20236Q166 (11) | |
See also: IR 05000302/1987035
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UNITED STATES
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NUCLEAR REGULATORY COMMISslON
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REGION 16
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101 MARIE 7TA STREET, N.W.
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ATLANTA, GEORGI A 30323
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NOV 161987
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Report No.: 50-302/87-35
Licensee:
Florida Power Corporation
3201 34th Street, South
St. Petersburg, FL 33733
Facility Name: Crystal River
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Docket No.: $0-302
License No.: DRP-72
Inspection Conducted: 0 ober 14-16, 1987
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Inspecto :
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R. E. Weddin ton
<Date/ Signed
Approved by:
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C M. Hosey, Section Chief
oate' Signed
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Division of Radiation Safety and Safeguards
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SUMMARY
Scope:
This was a special unannounced inspection to review the circumstances
surrounding the removal of lead bricks serving as the access barrier'to the
reactor cavity area.
Results:
Three violations were identified:
(1) failure to lock, post,
barricade, and to issue a Radiation Work Permit to control' access to a high
radiation area, (2) failure to adequately provide instruction to.a worker in
the restricted area, and (3) failure to establish adequate radiation protection
and refueling operations procedures.
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8711190220 871116
ADOCK 05000302
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REPORT DETAILS
1.
Persons Contacted
Licensee Employees
- P. F. McKee, Station Manager
- B. J. Hickle, Manager, Nuclear Plant Operations
- M. S. Mann, Nuclear Compliance Specialist
- S. G. Johnson, Manager, Site Nuclear Services
- G. A. Becker, Manager, Site Nuclear Engineering Services
- J. Lander, Manager, Nuclear Maintenance and Outages
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- R. E. Fuller, Senior Nuclear Licensing Engineer
- J. Cooper Nuclear Technical Support Superintendent
- S. Robinson, Nuclear Chemistry and Radiation Protection Superintendent
- D. Wilder, Radiation Protection Manager
- J. Alt'erdi, Assistant Director, Nuclear Plant Operations
- A. Kazemfar, Supervisor, Radiological Support Services
- D. Watson, Training Specialist
- F. R. Baily, Projects Superintendent
D. Parter, Operations Shift Supervisor
D. Jones, Operations Assistant Shift Supervisor
S. Young, Nuclear Auxiliary Operator
R. J. Rehburg, Nuclear Auxiliary Operator
M. Wilson, Nuclear Auxiliary Operator
S. Burbank, Reactor Operator
P. Ellsberry, Training Department
D. Mills, Health Physics Technician
R. Browning, Health Physics Supervisor
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M. Siapno, Health Physics Supervisor
R. S. Trentham, Health Physics Supervisor
R. Burleigh, Chief Health Physics Technician
Other licensee employees contacted included training instructors,
technicians, security and office personnel.
Nuclear Regulatory Comission
- T. Stetka, Senior Resident Inspector
- Attended exit interview
2.
Exit Interview (30703)
The inspection scope and findings were summarized on October 16, 1987,
with those persons indicated in Paragraph I above. Three violations were
discussed in detail:
(1) failure to lock, post, barricade, and to issue a
Radiation Work Permit to control access to a high radiation area
(Paragraph 3.D.(1)), (2) failure to adequately provide instruction to a
worker in the restricted area (Paragraph 3.D.(2)), and (3) failure to
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establish adequate radiation protection and refueling operations
procedures (Paragraph 3.D.(3)).
The licensee acknowledged the inspection
findings and took no exceptions.
The licensee did not identify as
proprietary any of the material provided to or reviewed by the inspector
during this inspection.
3.
Onsite Followup of Reactor Cavity Access Shielding Removal Event (93702)
a.
Description of Events
0n the evening of October 8, 1987, the licensee was making plans to
fill the reactor vessel to above the flange level with the seal plate
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installed so that the fuel transfer canal could be flooded and
defueling operations could commence. - A prejob briefing was conducted
by the Shift Suoervisor 'in the Control Room on the applicable
procedure, Operating Procedure (0P)-404, Decay Heat Removal System,
Revision 59, November 26, 1986, Section 15.
It was determined that
three watchstanders would be needed inside the Reactor Building to
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check for leakage from the seal area when the water level exceeded
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the 135 foot level.
The three watchstanders would be positioned on
the refuel floor at the fuel transfer canal, on the standpipe
indicating reactor vessel water level and at the entrance to the
reactor cavity area on the 95' elevation.
Two Auxiliary Nuclear
Operators (AN0s) were already inside the Reactor Building on another
job and it was decided to use them as two of the watchstanders.
A
licensed reactor operator entered the reactor building and met the
two AN0s.
They were informed of the upcoming evolution.
One was
sent to observe the fuel transfer canal and the other to the access
to the reactor cavity area.
The access to the reactor cavity area was an approximately 3' X 3'
penetration through the shield wall that opened directly to the area
beneath the reactor vessel.
There was a wall of lead bricks stacked
within the opening and a second wall of bricks was stacked outside
the opening.
When the AN0 arrived at the watch station, he removed
several lead bricks so that he could observe the area under the
reactor vessel with a flashlight.
The AN0 had a portable gamma
survey meter with him which could measure radiation levels up to
5 Roentgens / hour (R/hr).
The AN0 held the survey meter at the
opening and his meter went offscale high.
He then looked into the
opening using a flashlight and observed there was no apparent
leakage,
after which he waited to the side of the opening for the
word to be passed that the water level was above the 135' level.
Approximately twenty minutes later, another AN0 reported to the
cavity access area as the shift change relief.
The oncoming ANO was
told by the ANO initially assigned to the area to wait by the opening
until the water level was above 135' and then to hold her dosimetry
next to her head and look into the opening for leakage. She was to
notify the Control Room of her observation and then to replace the
lead bricks that had been removed. She was also warned that the area
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around the opening was " hot" and that she should warn any passersby
to hurry past the area.
After the ANO left, the relieving ANO also placed her dose rate
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instrument at the opening and it also exceeded the maximum reading of
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5 R/ hour.
About five minutes after she took over the watch station,
a licensee health physics technician and several contractor personnel
that had been working on steam generator sludge lancing passed by the
area on their way to the Reactor Building exit. The ANO warned them
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to hurry through the area. The health physics technician inquired as
to what the problem was and then observed the lead bricks that had
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been removed from the lead shield wall.
He placed his R0-2 survey
instrument in the opening und the dose rates exceeded the instruments
maximum scale of 50 Rem / hour.
He immediately directed one of the
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contractors, who was following behind to guard that approach to the-
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area and that the ANO should guard the other.
He sent the other
contractors out of the area and went to a phone on the next elevation
to report the situation to the health physics supervisor.
He then
went back to the area and told the AN0 to exit the Reactor Building.
b.
Licensee Corrective Actions
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The health physics supervisor notified the Control Room of the event
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and recommended that the Reactor Building be evacuated.
An
announcement was made for everyone to leave the Reactor Building and
to avoid the area in the vicinity of the reactor cavity access. The
health physics supervisor directed that written statements be
obtained from everyone exiting the reactor building.
By this time,
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the ANO that removed the lead bricks exited the area and it was found
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that his 0-200 millirem pocket dosimeter was offscale and that his
0-1 Rem pocket dosimeter read approximately 450 millirem.
The health physics supervisor went to the reactor cavity access area
with several other health physics technicians.
The opening was
surveyed and a maximum dose rate of 55 R/ hour was found.
A narrow
beam of radiation was emanating from the opening.
The dose rate at
approximately 5' from the opening was 20 Rem / hour.
The lead bricks
were replaced and the area was resurveyed. The dose rate at contact
with the shield wall was 50 mil 11 roentgen / hour. The shield wall was
posted:
"High radiation area inside, do not remove lead bricks."
Plant management was notified of the event and a mar,agement review
team was formed to immediately investigate the event and formulate
corrective actions.
The following actions were planned and/or taken:
(1) Exposure evaluations were performed for personnel that had been
in the Reactor Building.
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(2) The exposure received by the ANO was verified by a mock up
demonstration.
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(3) A memorandum was issued from the Plant Manager to all radiation
workers stating that they were not to place or remove any
shielding without specific instructions or concurrence from
health Physics personnel or;the ALARA Specialist.
(4) A locked barrier was to be placed across the reactor cavity
access opening.
Health physics personnel performed 15 minute
checks of the area to ensure that no bricks had been removed
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until the access could be locked.
(5) A statement was added to radiation work permits requiring that
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health physics be notified when the scope of work changes.
(6) Training on instrument usage was given to personnel checking out
a dose rate instrument.
A statement was added to the instrument'
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sign-out form that required the person sign that he understood
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the use of the instrument.
(7) Signs were posted at the reactor and auxiliary building
entrances and at the radiation work permit sign-in desk stating
that health physics approval was required to place or remove any-
shielding.
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(8) Other areas were reviewed to determine if a similar problem
existed.
c.
Inspector Followup
The inspector discussed the event with licensee representatives and
interviewed personnel who had been associated with the ' event.
The
inspector reviewed records assembled by the licensee as part of their
investigation.
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The inspector discussed posting of the shield wall with licensee
representatives.
At the time of the event there was no posting on
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the shield wall.
Licensee representatives stated that they could
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recall that during previous outages signs had been posted which
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stated that the area was a high radiation area and that the bricks
should not be removed.
The inspector asked if there was a procedure
which specified that certain areas within the Reactor Building always
be posted following a shutdown.
Licensee representatives stated that
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there was no such list and the decision on what areas to post was
based on supervisor review of the initial entry radiation survey.
At
the time of the event, a swing gate at the entrance to the "D Ring"
on the 95' elevation was posted as a high radiation area.
A number
of areas within the "D Ring" were also posted and were either locked
or a flashing light was positioned nearby.
However, there had been
no posting on the shield wall at the access to the reactor cavity.
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The inspector examined the radiation work permit (RWP) under which
the AN0 had worked. RWP R87-368 was titled, " Inspections, Valve Line
Ups, Hanging Tags, Defucl and Refuel."
This was a general RWP and
did not contain any requirements specific to a given job such as
filling the fuel transfer canal.
The RWP required that the health
physics office be contacted prior to- each entry. 'The two AN0s that
were initially in the Reactor Building had signed in on this RWP.
When they were switched to checking for leaks they did not notify
health physics and were not required to do so by procedure since they
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were already in the area. The licensed operator who had attended the
prejob briefing also signed in on RWP R87-368.
Health physics was
told by the operator that he was going into the Reactor Building to
check for leaks. No other information was exchanged.
The inspector reviewed the procedure that had been used to fill the
reactor vessel and fuel transfer canal, OP-404.
The procedure did
not discuss sending watchstanders to look for leakage during the
filling evolution and therefore did not contain any precautions about
avoiding the reactor cavity area.
The procedure did not discuss the
prejob briefing or who was required to attend.
Licensee
representatives stated that the stationing of watchstanders to check
for leaks and holding a prejob briefing were common practices' for
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this evolution.
However, they were not requirements and whether or
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not they were performed was left to the discretion of the shift
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supervisor.
The inspector reviewed the dose evaluations that had been performed
for the personnel that had been in the Reactor Building.
Only the
ANO who had removed the lead bricks received any significant
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exposure.
The AN0's thermoluminescent dosimeter (TLD) read 433
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milli rem.
The day after the event the ANO demonstrated for licensee
health physics management his activities in the Reactor Building,
including his body position and dosimetry placement while the lead
bricks were being removed.
The licensee determined that the AN0's
dosimetry may have been in the area of highest exposure only
approximately one third of the time, so they multiplied the TLD
reading by a factor of four to produce a conservative exposure
estimate of 1764 millirem to the whole body.
The licensee then
ratioed the contact and 18 inch radiation measurements at the opening
to the reactor cavity area to produce a factor to apply to the whole
dose value to estimate the AN0's extremity exposure. The result was
6615 millirem.
The inspector determined that these exposure
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estimates were appropriate.
The exposures were well within the NRC
quarterly exposure limits of 3 Rem to the whole body and 18.75 Rem to
the extremities.
The inspector reviewed the statements from individuals who had been
in the Reactor Building at the time of the event.
Seven individuals
stated that they had observed the AN0 removing the lead bricks as
they were passing by the area.
Two individuals indicated that they
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had challenged what the ANO was doing, but had been. told by the ANO
that he knew what he was doing.
Several of the statements indicate
that personnel had been given instructions by the ANO to minimize
their exposure, such as to move rapidly past the area.
The inspector interviewed licensee representatives concerning the
history of the lead brick wall that had been placed across the
opening to the reactor cavity area.
The wall had apparently been -
erected many years ago, and although there was no record indicating
the exact date, several of the present day health physics staff had
participated in establishing the wall and they recalled that it had
been before initial unit operation.
Shims made from half and quarter
section bricks had been driven with sledgehammers to fix the bricks
that had been placed within the entrance.
An unsecured wall of
bricks was then placed across the outside.- Within the opening there
was also a netal door that had been locked.
Prior to the most recent
event, there had been two previous entries into the cavity area
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during outages.
Little information was recalled about the first
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entry other than it was a fast inspection of the area.
The second
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entry occurred during the previous refueling outage in 1985.
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entry was made to perform inspections and take measurements to
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suppert preplanning of work that was being considered in the area
during a future outage.
At this time, the reactor was defueled and
the TIPS were withdrawn from the area so that the general area
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radiation levels were only about 800 mR/ hour.
Licensee personnel
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recalled that a significant amount of time was required to access the
area, first to remove the inner wall using a wrecking bar or similar
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tool and then the lock had to be cut from the inner metal door
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because no key could be found.
Following the entry, the bricks were
replaced by crafts personnel that were present. _ There were no
written specifications for replacing the shield wall and apparently
the bricks were not placed in as substantial a manner as they had
been originally. Also, since the ANO stated that when he removed the
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lead bricks, he could see into the cavity area, the metal door had
also apparently been left open.
The ANO later confirned that the
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door was open.
The ANO who removed the lead bricks had been present during the 1985
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cavity entry.
The ANO stated that he did not expect the radiation
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levels in the reactor cavity to be high and that removal of the lead
bricks would not result in significant dose rate at the cavity
access.
He was not aware that the TIPS were positioned in different
location which cause radiation levels in the reactor cavity to be
very high.
The ANO also stated that he was aware, based on his 1985 entry, that
the floor level in the cavity was approximately 2 feet below the
opening and, if there was a leak, several hundred gallons of water
would have accumulated by the time leakage could have been observed
coming through the shield wall and that there would then be no way to
stop the leak before the entire 95' elevation was contaminated.
He
believed that since he had been instructed to observe for leakage,
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that it had been intended that he access the cavity area so that he
could detect leakage at an early stage.
The inspector determined by
discussions with licensee personnel and review of records that the
method for checking for leakage was not detailed in a plant
procedure, discussed at the prejob briefing or discussed during the
conversation the AN0 had with the licensed operator who entered the
Reactor Building and sent him to the 95' elevation. The AN0 had been
given a portable radio and his only transmission to the Control Room
was that he was on station and observing for leakage. The removal of
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a portion of the shield wall was not mentioned.
The inspector reviewed the training that had been given to the AN0
and discussed this training with licensee training instructors and
supervisors.
He had last attended general employee training (GET)
requalification on August 6,1987.
The inspector reviewed the GET
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lesson plans.
There was a section on shielding and a note for the
instructor to make the point that temporary shielding should not be-
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placed or removed without health physics approval. The use of survey
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instruments was covered to the extent that the use of the Eberline
E130 portable beta-gamma' survey meter was demonstrated.
The actual
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instrument given to radiation workers (and the AN0 at the time of the
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event), was not covered.
The review of lesson plans and discussions
with licensee instructors indicate that no instruction on possible
failure modes of the instrument, its response in high fields or
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actions to take is given to workers.
One instructor stated that
students are told that health physics should be notified if the dose
rate exceeds the level indicated on the RWP or if the meter reading
is erratic.
In regard to high radiation areas, the GET lesson plans
stated that if an area exists where dose rates exceed 1 R/hr a
flashing light or locked gate will be used to warn the worker of this
condition.
The inspector also reviewed the individual's ANO qualification
standards.
The standard included health physics performance
requirements such as operation of portable radiation. monitoring
equipment and application of radiation and contamination safety
procedures.
These check-outs were signed off by senior reactor
operators (SRO).
The inspector discussed the qualification program
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with licensee representatives.
Licensee representatives stated that
they would consider getting health physics personnel involved in
health physics related check-outs for operators.
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The inspector reviewed the responses the licensee had taken to three
previous NRC Information Notices (ins) that addressed unauthorized
entries into the reactor cavity area at other facilities, and the
exposure of personnel, or potential for such exposure to intense
radiation fields of such magnitude as.to jeopardize personnel health
and safety.
ins 82-51, " Overexposure
in PWR' Cavities," 84-19, "Two
Events Involving Unauthorized Entries into PWR Reactor Cavities," and
86-107, " Entry into PWR Cavity with Retractable Incore Detector
Thimbles Withdrawn," had been received by the licensee.
IN 82-51 was
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sent to the 'SR0s at the time it was t received.
IN 84-19 was.sent to
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the health physics group.
A Field Problem Report was generated in
response to -IN 84-19 which ' recommended that the following. four
actions be taken:
(1)
Insta11' a strongback on the existing' lead brick' barricade witha
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an appropriate locking device, or
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(2) Design, fabricate, and install a lead plug. of equal- or. greater -
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thickness as the existing lead brick. barricade with ~ the'same
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locking de'vice as #1.
(3) Mount a conspicuous sign stating, " Danger - No Entry Without-
Approval.of the Plant Manager."
(4) The Plant Manager or his designee will have control; of the key.
These recommendations were approved by the Nuclear Chemistry and
Radiation Protection Superintendent on April 13, 1984,
A document.
dated September 17, 1984, from the Nuclear Compliance Section
indicated that the .reconsnendations were rejected.
A note on the.-
document stated that the access hole had been bricked up and a crane
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was needed to remove the bricks.
It also stated that no reason was
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seen to mount the sign.
In.1985, another initiative was made by the
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health physics group to implement the recommendations.-
The~ work
order request had not been acted on at the time of this event.
IN 86-107 was evaluated by the licensee and the documentation' filed
with the IN stcted that controls at Crystal River 3 were sufficient
to prevent overexposure due to entry. into the lower portion of the
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D-rings while incore instruments are partially withdrawn.
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The inspector determined through interviews with training department
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personnel that the three ins had not been included in licensed
operator or auxiliary operater training.
INPO Significant Operating
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Experience Report -(S0ER) 85-3, which covered essentially the same
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topics as the ins also had not been incorporated into any training,
although licensee representatives stated that'they. planned to include-
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some of these operating events into future GET classes.
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d.
Regulatory Implications
(1) Technical Specification 6.12.1' requires that a . high radiation:
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area in which the - intensity of' radiation is greater than .
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1,000 millirem per hour be barricaded and conspicuously posted -
as 'a High Radiation Area. and entrance thereto controlled' by.
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doors shall. a Radiation Work Permit and in' addition, locked -
issuance of
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be provided to prevent unauthorized entry. into such-
areas.
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Since the 1985 outage and reactor cavity entry, the access to
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the cavity area was not provided with a locked door or
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equivalent.
Prior to 1985, the access' inner door was . closed
and locked and the lead bricks required substantial effort with
a tool to remove.
After the 1985 entry, the door was left open
and the bricks were readily removable.
Failure to provide a
locked door to control access to the reactor cavity area after
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the 1985 entry was . identified as an apparent violation of
Technical Specification 6.12.1 (50-302/87-35-01).
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When'the bricks were removed from the reactor cavity access, a
high radiation area of 40 R/hr at 18 inches from the access was
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created that was uncontrolled with respect to barricading,
posting and controlling access by RWP for a period of
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approximately 30 to 45 minutes until it was discovered and
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controlled by health physics.
During this time, two individuals
worked in the vicinity of the opening and at least seven
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individuals walked through the field.
Failure to adequately
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control access to the high radiation area was identified as
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another example of an apparent violation of Technical
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Specification 6.12.1 (50-302/87-35-01).
(2) 10 CFR 19.12 requires that all individuals working in or
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frequenting any portion of a restricted area be instructed
in the purposes and functions of protective devices employed;
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shall be instructed of their responsibility to report promptly
te the licensee any condition which may lead to or cause a
violation of Commission regulations and licenses or unnecessary
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exposure to radiation or to radioactive material and shall be
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instructed in the appropriate response to warnings made in the
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event of any unusual occurrence or malfunction that may involve
exposure to radiation or radioactive _ material.
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also states that the extent of these instructions shall be
commensurate with potential radiological health protection
problems in the restricted area.
The ANO who removed the lead bricks was not aware of the
limitations and possible failure modes of the radiation survey
instrument that had been provided for his use in controlling his
exposure in the restricted area.
The individual was not aware
of the appropriate response to take when the radiation level
present exceeded the maximum scale reading on his radiation
survey meter.
The individual was not aware that health physics
should have been notified of the uncontrolled high radiation
area at the access to the reactor cavity and the unexpected
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radiation levels in the vicinity of that access.
The fact that
the second ANO was also unaware of many of these things suggests
weaknesses in the effectiveness of the training program rather
than an individual deficiency.
Failure of the licensee to
provide adequate instruction in the. areas required was
identified as an apparent violation of 10 CFR 19.12
(50-302/87-35-02).
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(3) Technical Specification 6.11 requires that procedures for
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personnel radiation protection shall be prepared consistent with
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the' requirements of 10 CFR Part 20 and shall be' approved,-
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maintained and adhered to for all operations involving personnel
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radiation exposure.-
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Technical Specification 6.8.1.b requires that written procedures
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shall be established, implemented, . and . maintained covering
refueling operations.
Following the 1985 cavity entry, the bricks. across the access.
were not replaced in as substantial a manner as they had been
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originally and the inner door was not closed and locked. There
was no procedure for the replacement of this shield wall and no
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requirement that health . physics approve of the manner in which
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the cavity access was barricaded.
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The licensee had no procedure which required that workers notify
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health physics when radiological conditions change or job- scope
changes.
There was no procedure which specified ' the controls-
for the removal of permanent shielding.
Following unit
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shutdown, there was no- guidance concerning posting of areas -
known to always be high radiation areas.
As a result,' posting
of areas was not consistent from outage to outage.
During
previous outages, the shield wall was apparently posted as a
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high radiation area and, on at least one occasion, also stated a
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prohibition against removing any . lead bricks.
However, the
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shield wall was not posted with warning signs at the time of.
this event.
The operations procedure for' filling the fuel transfer canal,
OP-404, did not specify the criteria for posting watchstanders
to check for seal leakage and the precautions they were' to
observe, particularly in regard to entering'the reactor cavity
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area.
The procedure did not require that a' prejob' briefing be'
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conducted for all the participants in the evolution. During the
inspection, several licensee employees made statements to the
effect that their procedures do not contain prohibitions against.
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many implausible acts and that they rely on workers to use
common sense.
However, as pointed out in the three ins
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documented above, entries into the reactor cavity with the TIPS
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withdrawn have occurred and the licensee should have specified
in their procedures for filling the transfer canal sufficient
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controls and precautions to ensure that' the participants were
aware of the hazards in the reactor cavity area,
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Failure of the licensee to establish adequate radiation
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protection and refueling operations procedures was identified as
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an apparent violation of Technical; Specification 6.11 and'
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6.8.1.b (50-302/87-35-03).
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