ML20236Q166

Insp Rept 50-302/87-35 on 871014-16.Violations Noted:Failure to Lock,Post Barricade & Issue Radiation Work Permit to Control Access to High Radiation Area & Failure to Provide Instructions to Worker in Restricted Area

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: ML20236Q144 ML20236Q166
References
50-302-87-35, NUDOCS 8711190220
Download: ML20236Q166 (11)

See also: IR 05000302/1987035

Text

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o UNITED STATES

- [p alc '% NUCLEAR REGULATORY COMMISslON

y . -gf REGION 16

g / g 101 MARIE 7TA STREET, N.W.

• t ATLANTA, GEORGI A 30323

% **, * / NOV 161987

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: a /"7

j C M. Hosey, Section Chief oate' Signed

l 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

PDR ADOCK 05000302 i

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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 '

• 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 l

• 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 1

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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 l

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 1

installed so that the fuel transfer canal could be flooded and I

defueling operations could commence. - A prejob briefing was conducted

by the Shift Suoervisor 'in the Control Room on the applicable i

procedure, Operating Procedure (0P)-404, Decay Heat Removal System, i

Revision 59, November 26, 1986, Section 15. It was determined that

three watchstanders would be needed inside the Reactor Building to l

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check for leakage from the seal area when the water level exceeded i

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 i

instrument at the opening and it also exceeded the maximum reading of i

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

l to hurry through the area. The health physics technician inquired as

to what the problem was and then observed the lead bricks that had l

l 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

l contractors, who was following behind to guard that approach to the-

l 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

. The health physics supervisor notified the Control Room of the event

l 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,

l the ANO that removed the lead bricks exited the area and it was found

i 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

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in the Reactor Building.

(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 i

until the access could be locked.

(5) A statement was added to radiation work permits requiring that j

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' l

sign-out form that required the person sign that he understood 1

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.

(8) Other areas were reviewed to determine if a similar problem

existed.

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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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l The inspector discussed posting of the shield wall with licensee

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representatives. At the time of the event there was no posting on

the shield wall. Licensee representatives stated that they could

i recall that during previous outages signs had been posted which

I 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

l 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

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health physics and were not required to do so by procedure since they

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

this evolution. However, they were not requirements and whether or

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l not they were performed was left to the discretion of the shift

I 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  ;

i exposure. The AN0's thermoluminescent dosimeter (TLD) read 433

l 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

l 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

l entry occurred during the previous refueling outage in 1985. An

l entry was made to perform inspections and take measurements to

l 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  !

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 i

tool and then the lock had to be cut from the inner metal door I

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

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been originally. Also, since the ANO stated that when he removed the ,

lead bricks, he could see into the cavity area, the metal door had

also apparently been left open. The ANO later confirned that the

door was open.

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The ANO who removed the lead bricks had been present during the 1985

l cavity entry. The ANO stated that he did not expect the radiation

! 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 ,

lesson plans. There was a section on shielding and a note for the

instructor to make the point that temporary shielding should not be- 1

placed or removed without health physics approval. The use of survey  !

instruments was covered to the extent that the use of the Eberline

E130 portable beta-gamma' survey meter was demonstrated. The actual l

instrument given to radiation workers (and the AN0 at the time of the '

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 ,

actions to take is given to workers. One instructor stated that

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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

l with licensee representatives. Licensee representatives stated that

they would consider getting health physics personnel involved in

health physics related check-outs for operators.

The inspector reviewed the responses the licensee had taken to three

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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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i sent to the 'SR0s at the time it was t received. IN 84-19 was.sent to

l 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 i

an appropriate locking device, or ]

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(2) Design, fabricate, and install a lead plug. of equal- or. greater -

I thickness as the existing lead brick. barricade with ~ the'same

l 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 ]

was needed to remove the bricks. It also stated that no reason was l

seen to mount the sign. In.1985, another initiative was made by the 1

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.

The inspector determined through interviews with training department j

personnel that the three ins had not been included in licensed

operator or auxiliary operater training. INPO Significant Operating ,

Experience Report -(S0ER) 85-3, which covered essentially the same l

topics as the ins also had not been incorporated into any training,

although licensee representatives stated that'they. planned to include- ,

some of these operating events into future GET classes. 'l

d. Regulatory Implications

(1) Technical Specification 6.12.1' requires that a . high radiation:

l area in which the - intensity of' radiation is greater than . ,

l 1,000 millirem per hour be barricaded and conspicuously posted -  ;

as 'a High Radiation Area. and entrance thereto controlled' by.  !

issuance of y

doors shall. be

a Radiation Work

provided to Permit

prevent and in' addition,

unauthorized entry. locked -

into such-

areas.

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Since the 1985 outage and reactor cavity entry, the access to ]

the cavity area was not provided with a locked door or 1

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 j

the 1985 entry was . identified as an apparent violation of  ;

Technical Specification 6.12.1 (50-302/87-35-01). j

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 j

created that was uncontrolled with respect to barricading,

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posting and controlling access by RWP for a period of ,

approximately 30 to 45 minutes until it was discovered and 1

controlled by health physics. During this time, two individuals l

worked in the vicinity of the opening and at least seven I

individuals walked through the field. Failure to adequately )

control access to the high radiation area was identified as )

another example of an apparent violation of Technical 1

Specification 6.12.1 (50-302/87-35-01).

(2) 10 CFR 19.12 requires that all individuals working in or ,

frequenting any portion of a restricted area be instructed  ;

in the purposes and functions of protective devices employed; j

shall be instructed of their responsibility to report promptly l

te the licensee any condition which may lead to or cause a  ;

violation of Commission regulations and licenses or unnecessary i

exposure to radiation or to radioactive material and shall be j

instructed in the appropriate response to warnings made in the j

event of any unusual occurrence or malfunction that may involve 1

exposure to radiation or radioactive _ material. 10 CFR 19.12 '

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 1

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 [

personnel radiation protection shall be prepared consistent with 1

the' requirements of 10 CFR Part 20 and shall be' approved,- ')

maintained and adhered to for all operations involving personnel 1

radiation exposure.-

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Technical Specification 6.8.1.b requires that written procedures 'j

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

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

! the cavity access was barricaded.

l The licensee had no procedure which required that workers notify

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  !

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

j high radiation area and, on at least one occasion, also stated a

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prohibition against removing any . lead bricks. However, the j

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 ,

area. The procedure did not require that a' prejob' briefing be' i

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. l

many implausible acts and that they rely on workers to use

common sense. However, as pointed out in the three ins .)

documented above, entries into the reactor cavity with the TIPS -

withdrawn have occurred and the licensee should have specified

in their procedures for filling the transfer canal sufficient  :

controls and precautions to ensure that' the participants were i

aware of the hazards in the reactor cavity area,

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Failure of the licensee to establish adequate radiation .

protection and refueling operations procedures was identified as  !

an apparent violation of Technical; Specification 6.11 and' ,

6.8.1.b (50-302/87-35-03).  !

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