ML20236R510
| ML20236R510 | |
| Person / Time | |
|---|---|
| Issue date: | 10/31/1987 |
| From: | NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD) |
| To: | |
| References | |
| NUREG-0090, NUREG-0090-V10-N01, NUREG-90, NUREG-90-V10-N1, NUDOCS 8711230326 | |
| Download: ML20236R510 (58) | |
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NUREG-0090 Vol.10, No.1 (Report to Congress on l Abnormal Occurrences January - March 1987 U.S. Nuclear Regulatory
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Available from Superintendent of Documents U.S. Government Printing Office Post Office Box 37082 Washington, D.C. 20013-7082 A year's subscription consists of 4 issues for this publication.
Single copies of this publication are available from National Technical Information Service, Springfield, VA 22161 l
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NUREG-0090 Vol.10, No.1 Report to Congress on Abnormal Occurrences January - March 1987 Date Published: october 1987 Office for Analysis and Evaluation of Operational Data U.S. Nuclear Regulatory Commission Washington, DC 20555
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Previous Reports in Series NUREG 75/090, January-June 1975, NUREG-0090 Vol.4, No.2, April-June 1981, published October 1975 pubiished October 1981 NUREG-0090-1, July-September 1975, NUREG-0090, Vol.4, ho.3, July-September 1981, published March 1976 published January 1982 NUREG-0090-2, October-December 1975, NUREG-0090 Vol.4, No.4, October-December 1981, published March 1976 published May 1982 NUREG-0090-3, January-March 1976, NUREG-0090, Vol. 5, ho.1, January-March 1982 published July 1976 published Au9ust 1982 NUREG-0090-4, April-June 1976, NUREG-0090, Vol.5, No.2, April-June 1962, published March 1977 published December 1982 NUREG-0090-5, July-September 1976, NUREG-0090, Vol.5, No.3, July-September 1932, published March 1977 pJblished January 1983 NUREG-0050-6, October-December 1976.
NUREG-0090, Vol.5, Nol4, October-December 1982, published June 1977 published May 1983 hUREG-0090-7, January-March 1977, NUREG-0090, Vol.6, No.1, January-March 1983, published June 1977 published September 1983 NUREG-0090-8, April-June 1977, NUREG-0090, Vol.6, No.2, April-June 1983, published September 1977 published November 1983 NUREG-0090-9, July-September 1977, NUREG-0090, Vol.6, No.3, July-September 1983, published November 1977 published April 1984 NUREG-0090-10, October-December 1977, NUREG-0090, Vol.6, No.4, October-December 1983, published March 1978 published May 1984 NUREG-0090, Vol.1, No.1, January-March 1978.
NUREG-0090, Vol.7, No.1, January-March 1984, published June 1978 published July 1984 NUREG-0090, Vol.1, No.2, April-June 1978, NUREG-0090, Vol.7, No.2, April-June 1984, published September 1978 published October 1984 NUREG-0090, Vol.1, No.3, July-September 1978, NUREG-0090, Vol.7, No.3, July-September 1984, published December 1978 published April 1985 NUREG-0090 Vol.1, No.4, October-December 1978, NUREG-0090, Vol.7, No.4, October-December 1984, published March 1979 published May 1985 NUREG-0090, Vol.2, ho.1, January-March 1979.
NUREG-0090, Vol.8, No.1, January-March 1985, published July 1979 published Au9ust 1985 NUREG-0090, Vol.2, No.2, April-June 1979, NUREG-0090, Vol.8, No.2, April-June 1985, published hovember 1979 published November 1985 NUREG--0090, Vol.2, No.3, July-September 1979, NUREG-0090, Vol.8, No.3, July-September 1985, publithed February 1980 published February 1986 NUREG-0090, Vol.2, No.4, October-December 1979, NUREG-0090, Vol.8, No.4, October-December 1985, published April 1980 published May 1986 1
NUREG+0090,VF.3,No.1, January-March 1980, NUREG-0090, Vol.9, ho.1, January-March 1986, I
published September 1980 published September 1986 NUREG-0090 Vol.3, No.2, April-June 1980, NUREG-0090 Vol.9, No.2, April-June 1986, published November 1980 published January 1987 NUREG-0090 Vol.3, No.3, July-September 1980, NUREG-0090, Vol.9, No.3, July-September 1986, published February 1981 published April 1987 NUREG-0090, Vol.3, No.4, October-December 1980, NUREG-0090, Vol.9, No.4, October-December 1986, published May 1981 published July 1987 NUREG-0090, Vol. 4, No. 1. January-March 1981, published July 1981
ABSTRACT Section 208 of the Energy Reorganization Act of 1974 identifies an abnor, rial occurrence as an unscheduled incident or event which the Nuclear Regulatery Commission determines to be significant from the standpoint of public health or safety and requires a quarterly report of such events to be made to Congress.
This report covers the period from January 1 to March 31, 1987.
The report states that for this reporting period, there was one abnormal occur-rence at the nuclear power plants licensed to operate.
The item involved the NRC suspension of power operations of the Peach Bottom Facility due to inatten-tiveness of the control room staff.
There were seven abnormal occurrences at the other NRC licensees.
Four involved diagnostic medical misadministration; the other three involved breakdowns in management controls at three separate industrial radiography licensees.
There were two abnormal occurrences reported by the Agreement States.
Both involved breakdowns in management controls at industrial radiography licensees.
The report also contains information updating some previously reported abnormal occurrences.
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CONTENTS Page ABSTRACT................................................................
iii PREFACE.................................................................
vii INTRODUCTION.......................................................
vii THE REGULATORY SYSTEM............................................
vii REPORTABLE OCCURRENCES.............................................
viii AGREEMENT STATES...................................................
x FOREIGN INFORMATION................................................
x REPORT TO CONGRESS ON ABNORMAL OCCURRENCES, JANUARY-MARCH 1987..........
1 NUCLEAR POWER PLANTS...............................................
1 87-1 NRC Order Suspends Power Operations of Peach Bottom Facility Due to Inattentiveness of the Control Room Staff.............
1 FUEL CYCLE FACILITIES (Other than Nuclear Power Plants)............
5 OTHER NRC LICENSEES (Industrial Radiographer, Medical Institutions, Industrial Users, etc.)............................
5 87-2 Diagnostic Medical Misadministration.........................
5 87-3 Diagnostic Medical Misadministration.........................
6 87-4 Diagnostic Medical Misadministration.........................
7 87-5 Significant Breakdown in Management Oversight and Control of Radiation Safety Program at Two of a Licensee's Irradiator Facilities...................................................
8 87-6 Diagnostic Medical Misadministration.........................
10 87-7 Significant Breakdown in Management Oversight and Control of Radiation Safety Program at an Industrial Radiography Licensee.....................................................
11 87-8 Significant Breakdown of Management Controls for Radiographic Operations......................................
13 AGREEMENT STATE LICENSEES..........................................
14 AS87-1 Breakdown in Management and Procedural Controls at an Industrial Radiography Licensee............................
14 AS87-2 Breakdown in Management and Procedural Controls at an Industrial Radiography Licensee.............
17 REFERENCES.......................................................
19 APPENDIX A - ABNORMAL OCCURRENCE CRITERIA..............................
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CONTENTS (continued)
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i' Page APPENDIX B - UPDATE OF PREVIOUSLY REPORTED ABNORMAL OCCURRENCES.........
23 NUCLEAR POWER PLANTS..............................................
23 79-3 Nuclear Accident at Three Mile Island.......................
23 85-7 Loss of Main and Auxiliary Feedwater Systems................
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85-12 Management Control Deficiencies....................
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86-9 Emergency Core Cooling System Mini-Flow Design Deficiency...
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86-16 Abnormal Cooldown and Depressurization Transient at J
Catawba Unit 2..............................................
28 OTHER NRC LICENSEES...............................................
29 86-6 Breakdown of Management Controls at an Irradiator Facility...................................................
29 APPENDIX C - OTHER EVENTS OF INTEREST...................................
31 1
i REFERENCES (FOR APPENDICES)..............................................
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PREFACE INTRODUCTION The Nuclear Regulatory Commission reports to the Congress each quarter under provisions of Section 208 of the Energy Reorganization Act of 1974 on any abnor-mal occurrences involving facilities and activities regulated by the NRC.
An abnormal occurrence is defined in Section 208 as an unscheduled incident or event which the Commission determines is significant from the standpoint of public health or safety.
Events are currently identified as abnormal occurrences for this report by the NRC using the criteria delineated in Appendix A.
These criteria were promulgated in an NRC policy statement which was published in the Federal Register on February 24, 1977 (Vol. 42, No. 37, pages 10950-10952).
In order to provide wide dissemination of information to the public, a Federal Register notice is issued on each abnormal occurrence with copies distributed to the NRC Public Document Room and all Local Public Document Rooms.
At a minimum, each such notice contains the date and place of the occurrence and describes its nature and probable consequences.
The NRC has reviewed Licensee Event Reports, licensing and enforcement actions (e.g., notices of violations, civil penalties, license modifications, etc.),
generic issues, significant inventory differences involving special nuclear material, and other categories of information available to the NRC.
The NRC has determined that only those events, including those submitted by the Agree-ment States, described in this report meet the criteria for abnormal occurrence reporting.
This report covers the period from January 1 to March 31, 1987.
Information reported on each event includes:
date and place; nature and probable consequences; cause or causes; and actions taken to prevent recurrence.
THE REGULATORY SYSTEM The system of licensing and regulation by which NRC carries out its responsibil-ities is implemented through rules and regulations in Title 10 of the Code of Federal Regulations.
To accomplish its objectives, NRC regularly conducts licensing proceedings, inspection and enforcement activities, evaluation of operating experience and confirmatory research, while maintaining programs for establishing standards and issuing technical reviews and studies.
The NRC's role in regulating represents a complete cycle, with the NRC establishing stan-dards and rules; issuing licenses and permits; inspecting for compliance; enforcing license requirements; and carrying on continuing evaluations, studies and research projects to improve both the regulatory process and the protection of the public health and safety.
Public participation is an element of the regulatory process.
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In the licensing and regulation of nuclear power plants, the NRC follows the philosophy that the health and safety of the public are best assured through the establishment of multiple levels of protection.
These multiple levels can be achieved and maintained through regulations which specify requirements which will assure the safe use of nuclear materials.
The regulations include design and quality assurance criteria appropriate for the various activities licensed by NRC.
An inspection and enforcement program helps assure compliance with the i
regulations.
l Most NRC licensee employees who work with or in the vicinity of radioactive materials are required to utilize personnel monitoring devices such as film badges or TLD (thermoluminescent dosimeter) badges.
These badges are processed periodically and the exposure results normally serve as the official and legal record of the extent of personnel exposure to radiation during the period the badge was worn.
If an individual's past exposure history is known and has been sufficiently low, NRC regulations permit an individual in a restricted area to 4
receive up to three rems of whole body exposure in a calendar quarter.
Higher j
values are permitted to the extremities or skin of the whole body.
For unre-q stricted areas, permissible levels of radiation are considerably smaller.
Per-missible doses for restricted areas and unrestricted areas are stated in 10 CFR Part 20.
In any case, the NRC's policy is to maintain radiation exposures to levels as low as reasonably achievable.
i REPORTABLE OCCURRENCES Actual operating experience is an essential input to the regulatory process for assuring that licensed activities are conducted safely.
Reporting requirements exist which require that licensees report certain incidents or events to the NRC.
This reporting helps to identify deficiencies early and to assure that corrective actions are taken to prevent recurrence.
For nuclear power plants, dedicated groups have been formed both by the NRC and by the nuclear power industry for the detailed review of operating experience to help identify safety concerns early, to improve dissemination of such infor-mation, and to feed back the experience into licensing, regulations, and operations.
In addition, the NRC and the nuclear power industry have ongoing efforts to improve the operational data system which include not only the type, and quality, of reports required to be submitted, but also the method used to analyze the data.
Two primary sources of operational data are reports submitted by the licensees under the Licensee Event Report (LER) system, and under the Nuclear Plant Reliability Data (NPRD) system.
The former system is under the control of the NRC while the latter system is a voluntary, industry-supported system operated by the Institute of Nuclear Power Operations (INPO), a nuclear utility organization.
Some form of LER reporting system has been in existence since the first nuclear power plant was licensed.
Reporting requirements were delineated in the Code of Federal Regulations (10 CFR), in the licensees' technical specifications, and/or in license provisions.
In order to more effectively collect, collate, store, retrieve, and evaluate the information concerning reportable events, the Atomic Energy Commission (the predecessor of the NRC) established in 1973 a viii I
computer-based data file, with data extracted from licensee reports dating from 1969.
Periodically, changes were made to improve both the effectiveness of data processing and the quality of reports required to be submitted by the licensees.
Effective January 1,1984, major changes were made to the requirements to report to the NRC.
A revised Licensee Event Report System (10 CFR S 50.73) was esta-blished by Commission rulemaking which modified and codified the former LER system.
The purpose was to standardize the reporting requirements for all nuclear power plant licensees and eliminate reporting of events which were of low individual significance, while requiring more thorough documentation and analyses by the licensees of any events required to be reported.
All such reports are to be submitted within 30 days of discovery.
The revised system also permits licensees to use the LER procedures for various other reports required under specific sections of 10 CFR Part 20 and Part 50.
The amendment to the Commission's regulations was published in the Federal Register (48 FR 33850) on July 26, 1983, and is described in NUREG-1022, " Licensee Event Report System," and Supplements 1 and 2 to NUREG-1022.
Also effective January 1, 1984, the NRC amended its immediate notification requirements of significant events at operating nuclear power reactors (10 CFR S 50.72).
This was published in the Federal Register (48 FR 39039) on August 29, 1983, with corrections (48 FR 40882) published on September 12, 1983.
Among the changes made were the use of terminology, phrasing, and reporting thresholds that are similar to those of 10 CFR S 50.73.
Therefore, most events reported under 10 CFR S 50.72 will also require an in-depth follow-up report under 10 CFR S 50.73.
The NPRD system is a voluntary program for the reporting of reliability data by nuclear power plant licensees.
Both engineering and failure data are to be submitted by licensees for specified plant components and systems.
In the past, industry participation in the NPRD system was limited and, as a result, the Commission considered it may be necessary to make participation manadatory in order to make the system a viable tool in analyzing operating experience.
How-ever, on July 8, 1981, INPO announced that because of its role as an active user to NPRD system data, it would assume responsibility for management and funding of the NPRD system.
INPO reports that significant improvements in licensee participation are being made.
The Commission considers the NPRD system to be a vital adjunct to the LER system for the collection, review, and feedback of operational experience; therefore, the Commission periodically monitors the progress made on improving the NPRD system.
Information concerning reportable occurrences at facilities licensed or other-wise regulated by the NRC is routinely disseminated by the NRC to the nuclear industry, the public, and other interested groups as these events occur.
Dissemination includes special notifications to licensees and other affected or interested groups, and public announcements.
In addition, information on reportable events is routinely sent to the NRC's more than 100 local public document rooms throughout the united States and to the NRC Public Document Room in Washington, D.C.
The Congress is routinely kept informed of reportable events occurring in licensed facilities.
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AGREEMENT STATES Section 274 of the Atomic Energy Act, as amended, authorizes the Commission to enter into agreements with States whereby the Commission relinquishes and the States assume regulatory authority over byproduct, source and special nuclear materials (in quantities not capable of sustaining a chain reaction).
Compar-able and compatible programs are the basis for agreements.
Presently, information on reportable occurrences in Agreement State licensed activities is publicly available at the State level.
Certain information is also provided to the NRC under exchange of information provisions in the agreements.
In early 1977, the Commission determined that abnormal occurrences happening at facilities of Agreement State licensees should be included in the quarterly reports to Congress.
The abnormal occurrence criteria included in Appendix A are applied uniformly to events at NRC and Agreement State licensee facilities.
Procedures have been developed and implemented and abnormal occurrences reported by the Agreement States to the NRC are included in these quarterly reports to Congress.
FOREIGN INFORMATION The NRC participates in an exchange of information with various foreign govern-ments which have nuclear facilities.
This foreign information is reviewed and considered in the NRC's assessment of operating experience and in its research and regulatory activities.
Reference to foreign information may occasionally be made in these quarterly abnormal occurrence reports to Congress; however, only domestic abnormal occurrences are reported.
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REPORT TO CONGRESS ON ABNORMAL OCCURRENCES JANUARY-MARCH 1987 NUCLEAR POWER PLANTS The NRC is reviewing events reported at the nuclear power plants licensed to operate during the first calendar quarter of 1987.
As of the date of this report, the NRC had determined that the following event was an abnormal occurrence.
87-1 NRC Order Suspends Pow'er Operations of Peach Bottom Facility Due to Inattentiveness of the Control Room Staff The following information pertaining to this event is also being reported con-currently in the Federal Register.
Appendix A (see Example 10 of "For All Licensees") of the report notes that a major deficiency in operation having safety implications requiring immediate remedial action can be considered an abnormal occurrence.
In addition, Example 11 of "For All Licensees" notes that a major deficiency in management or procedural controls in major areas can be considered an abnormal occurrence.
Date and Place - On March 31, 1987, the NRC issued an Order Suspending Power Operation and Order to Show Cause (Effective Immediately) to Philadelphia Elec-tric Company (the licensee).
The Order directed the licensee to place Peach Bottom Unit 3 (operating at about 100% power at the time) in cold shutdown (Unit 2 was already in cold shutdown for refueling) and maintain both Units in cold shutdown pending further Order (Ref. 1).
Peach Bottom Units 2 and 3 are General Electric-designed BWR/4 boiling water reactors located in York County, Pennsylvania.
Nature and Probable Consequences - The Order was based on the fact that at times during various shifts one or more of the Peach Bottom operations control room staff (including licensed operators, senior licensed operators, and shift super-visors) have for at least the past five months periodically slept or have been otherwise inattentive to licensed duties.
In addition, plant management either knew or condoned this inattentiveness, or should have known of these facts, and either took no action or inadequate action to correct this situation.
Prior NRC inspections have identified other instances of inattention to duty or failure to adhere to procedures on the part of licensed operators in the control room at Peach Bottom.
Details of the events which led to issuance of the Order are as follows.
On June 10, 1985, during the 11:00 p.m. to 7:00 a.m. shift, an NRC inspector was present in the Unit 3 control room and observed an on-duty Unit 3 reactor operator sitting in a chair at the Unit 3 reactor control panel with his eyes closed and his head tilted back, apparently asleep or otherwise inattentive to his duties.
In response to this charge the licensed operator denied being asleep and indicated he was enticing the NRC inspector to believe he was asleep; this demonstrated poor judgment and a negative attitude toward safety.
An Enforcement Conference was held with the licensee concerning this matter on June 21, 1985.
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1 On June 6,1986, the NRC issued its. Systematic Assessment of Licensee Performance (SALP) report for the period April i, 1985 through January 31, 1986.
This report concluded that management D alvement and effectiveness toward improving operating activities was not e; 6 L Indications of the lack of adequate management involvement included:
nor dissemination of management goals and policies; poor communications bets +t different departments and divisions; and a focus on compliance rather than,,anowledgement and correction of the root causes of problems.
Further, the report concluded there was a complacent attitude toward procedural compliance in plant operations.
On June 9, 1986, the NRC issued a Notice of Violation and Proposed $200,000 Civil Penalty for several violations that resulted from numerous personnel errors by several licensed operators, including the Shift Supervisor and Shift Super-intendent, both of whom are licensed senior reactor operators, and two licensed reactor operators.
These personnel errors involving improper out of sequence control rod withdrawal by four licensed individuals and associated violations, indicated a pattern of inattention to detail, failure to adhere to procedural requirements, and a generally complacent attitude by the operations staff toward performance of their duties at Peach Bottom (Ref. 2).
This event was reported as abnormal occurrence A0 86-8 ("Out of Sequence Control Rod Withdrawal") in NUREG-0090, Vol. 9, No. 2 (" Report to Congress on Abnormal Occurrences:
April-June 1986").
During the period from June 18, 1986 to July 3 1986, ten members of a Region I team conducted a special diagnostic safety inspection of operational and other activities at the Peach Bottom facility.
The objective of the inspection was to gain a more complete understanding of the underlying reasons for the poor performance described in the June 1986 SALP Report.
Although the inspection found no evidence that the plant was being operated unsately, the results con-firmed the conclusions reached in the June 1986 SALP report regarding the need for improved licensee performance at Peach Bottom.
In addition to the above, there had been three previous civil penalties issued (on March 29, 1983; June 13, 1983; and June 18, 1984) for violations resulting from personnel errors.
In general, the enforcement history at Peach Bottom regarding adherence to procedures and attention to duty has been poor.
On March 24, 1987, NRC Region I received information that control room operators at Peach Bottom had been observed sleeping while on duty in the control room and were otherwise inattentive to their license obligations.
The information also indicated that this conduct on the part of operators was pervasive and had been occurring for some time, and that shift supervision had knowledge of this situation.
On March 24, 1987, in response to this information, NRC initiated:
(1) 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> inspection coverage of the Peach Bottom control room and (2) a special safety investigation of licensed activities.
The NRC investigation, which is still ongoing, to date has established:
1.
At times during various shifts, in particular the 11:00 p.m. to 7:00 a.m.
shift, one or more of the Peach Bottom operations control room staff (including licensed operators, senior licensed operators and shift super-vision) have for at least the past five months periodically slept or have been otherwise inattentive to licensed duties.
2.
Management at the Shift Supervisor and Shift Superintendent level have either known and condoned the facts set forth in Item 1 above, or should have known of these facts.
3.
Plant management above the shift superintendent position either knew or should have known the facts set forth in Item 1 above and either took no action or inadequate action to correct this situation.
NRC regulations prohibit sleeping or otherwise inattentive operators in the control room.
Under 10 CFR Part 50, Appendix B, the licensee must have and implement procedures to ensure that activities affecting quality, ircluding operations of the facility, are satisfactorily accomplished.
The Pehch Bottom quality assurance program failed to identify these conditions adverse to safety.
These conditions constituted a hazard to the safe operations of the facility.
The NRC expects licensees to maintain high standards of control room profes-sionalism.
NRC licensed operators in the control rooms at nuclear power plants are responsible for assuring that the facility is operated safely and within the requirements of the facility's license, technical specifications, regulations, and orders of the NRC.
To be able to carry out these highly important respon-sibilities, reactor operators must give their full attention to the condition of the plant at all times.
Operators must be alert to ensure that the plant is operating safely and must be capable of taking timely action in response to s
plant conditions.
All control room business must be conducted in such a way that neither control room operator attentiveness nor the professional atmosphere will be compromised.
Sleeping while on duty in the control room demonstrates a total disregard for performing licensed duties and a lack of appreciation for what those duties entail.
In light of the above, it was apparent that the licensee, through its enforce-ment history and from what had been developed by the ongoing investigation, knew or should have known of the unwillingness or inability of its operations staff to comply with Commission requirements, and had been unable to implement effective corrective action.
Consequently, the NRC lacked reasonable assurance that the facility would be operated in a manner to assure that the health and safety of the public would be protected and therefore determined that the public health, safety and interest required that the licensee place and maintain its units in cold shutdown.
Cause or Causes - There are several factors which contributed to this event.
The licensed operators failed to execute their duties in a responsible manner which indicates an apparent lack of appreciation of the safety significance of those duties.
Plant management failed to take adequate actions to identify or correct the problem.
Also, the Peach Bottom Quality Assurance program was ineffective in identifying this issue which had significant safety implications.
Actions Taken to Prevent Recurrence Licensee - A final recovery action is currently being formulated by the licensee; however, the following actions have already been taken:
1)
Plant management changes have occurred including the replacement of the Plant Manager and the Operations Engineer.
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2)
The Management Analysis Company (MAC) was retained to assist in the inves-tigation and advise the licensee on the development of a recovery plan.
MAC is advising an in-house review organization headed by the President and Chief Operations Officer of the licensee and will focus on a root cause evaluation.
3)
A committee of outside directors from the licensee's Board of Directors was formed to review the results of the investigation.
Admiral Eugene P.
Wilkinson, Past President of the Institute of Nuclear Power Operations (INPO), will serve as a consultant to this committee.
4)
INP0 has agreed to provide an assistance team of professional nuclear industry personnel to perform an independent analysis of Peach Bottom operations.
NRC - The NRC Order dated March 31,1987 (Ref.1) specified the following:
1)
The licensee was required within 36 hours4.166667e-4 days <br />0.01 hours <br />5.952381e-5 weeks <br />1.3698e-5 months <br /> from receipt of the Order to shut down Unit 3 and place tne Unit in the cold condition (reactor coolant temperature equal to or less than 212 F) and maintain both Units in the cold condition with the reactor mode switch either in the refueling or shutdown mode pending further Order.
2)
The licensee was required to provide to the Administrator of Region I within seven days of the Order a description of the actions the licensee planned to take to provide assurance that the facility would comply with all requirements, including station procedures while in a cold condition.
3)
Before the licensee proposed to operate either Unit 2 or Unit 3 above a cold condition, the licensee will be required to provide to the Adminis-trator of Region I, for his approval, a detailed and comprehensive plan and schedule to accomplish the plan to assure that the facility will safely operate and comply with all requirements including station procedures.
The NRC Region I office is continuing to monitor the actions being taken by the licensee as a result of the Order.
Several meetings have been held during which the licensee briefed Region I management on the status of their investigations.
One specific item of discussion was actions to be taken to ensure that reload-ing of fuel into Unit 2 could be accomplished in a safe manner.
NRC Information Notice No. 87-21 was issued on May 11, 1987 to all licensees to inform them of the Peach Bottom event and to again emphasize the NRC's posi-tion that operator attentiveness is a vital element in the safe operation of a nuclear power plant (Ref. 3).
Future reports will be made as appropriate.
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I FUEL CYCLE FACILITIES l
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(Other Than Nuclear Power Plants) 1 The NRC is reviewing events reported by these licensees during the first calen-l dar quarter of 1987.
As of the date of this report, the NRC had not determined l
1 that any events were abnormal occurrences.
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j OTHER NRC LICENSEES J
(Industrial Radiographer, Medical Institutions, l
Industrial Users, etc.)
There are currently about 9,000 NRC nuclear material licenses in effect in the j
United States, principally for use of radioisotopes in the medical, industrial, l
and academic fields.
Incidents were reported in this category from licensees such as radiographer, medical institutions, and byproduct material users.
The NRC is reviewing events reported by these licensees during the first calen-dar quarter of 1987.
As of the date of this report, the NRC had determined i
that the following events were abnormal occurrences.
87-2 Diagnostic Medical Misadministration 1
The following information pertaining to this event is also being reported con-currently in the Federal Register.
Appendix A (see the general criterion) of-l J
this report notes that an event involving a moderate or more severe impact on public health or safety can be considered an abnormal occurrence.
Date and Place - In a January 5,1987 letter, Allegheny Valley' Hospital, Natrona Haights, Pennsylvania, notified NRC Region I that on November 21, 1986, a patient l
received an intravenous dose of 100 millicuries of technetium-99m rather than the prescribed dose of 20 millicuries.
Nature and Probable Consequences - On November 21, 1986, a technologist prepared a 20 millicurie syringe of technetium-99m to be used for a brain scan.
The i
syringe was properly labeled.
The technologist, while waiting for the brain scan patient to arrive, prepared a syringe of 100 millicuries of technetium-99m to be used in preparing multiple doses of another radiopharmaceutical.
As she completed preparation of the 100 millicurie syringe, the telephone rang and she put down the 100 millicurie syringe.
While the technologist was on the telephone, the brain scan patient arrived.
As soon as the telephone call was finished, the technician mistakenly grabbed the syringe containing 100 milli-curies and injected the patient.
As a result, the patient received five times the prescribed dose of the radiopharmaceutical.
Estimated deses to various organs of the patient are:
stomach wall, 25 rads; thyroid, 13 rads; intestinal wall, 6-7 rads; and bladder wall, 5 rads.
These doses are about five times those which would have been expected had the prescribed 5'
doses been administered.
The Nuclear Medicine physician examined the patient and decided that there was no adverse effect on the patient and that no action regarding patient care was needed.
Cause or Causes - The cause was due to human error by the technologist.
Actions Taken to Prevent Recurrence Licensee - The licensee concludes that a cause of the misadministration was that the technologist was rushed and doing too many duties at once.
As a result, the licensee states that it is committed to reorganizing the scheduling respon-sibilities for nuclear medicine personnel.
However, the corrective actions described are not sufficiently specific and have not yet been implemented.
NRC - The licensee's corrective actions were reviewed by Region I during an inspection on February 4, 1987.
Region I has requested that the licensee des-cribe and take more comprehensive and specific corrective actions.
Unless new, significant information becomes available, this item is considered closed for the purposes of this report.
87-3 Diagnostic Medical Misadministration The following information pertaining to this event is also being reported con-currently in the Federal Register.
Appendix A (see the general criterion) of l
this report notes that an event involving a moderate or more severe impact on public health or safety can be considered an abnormal occurrence.
Date and Place - On January 21, 1987, NRC Region IV was notified by St. Anthony Hospital, Oklahoma City, Oklahoma, that on January 12, 1987, a 15 year old female was administered 400 microcuries of I-131 rather than the prescribed dose of 400 microcuries of I-123, resulting in a thyroid dose of about 1490 rads.
Nature and Probable Consequences - The patient had been scheduled for a diag-nostic, thyroid update study.
The diagnostic procedure called for 400 micro-curies of I-123 in capsule form to be administered orally.
Four capsules (100 microcuries each) had been ordered by telephone from the University of Oklahoma Regional Nuclear Pharmacy.
The technologist who placed the order maintained that the proper isotope and dose had been ordered, although no record of the phone order was made.
When the dose was delivered on January 12, 1987, the package was correctly labelled as 0.40 millicurie of I-131 capsules.
However, not checking the label, and assuming the capsules were I-123, the technologist assayed the dose in the calibrator using the I-123 window.
The dose calibrator purportedly assayed about 340 microcuries which, considering decay, would be expected for four capsules of I-123.
Again, without checking the label, the I-131 capsules were administered to the patient.
The scan was performed the next day and the scatter observed indicated that the isotope was I-131 rather than I-123.
6
i The licensee calculated the thyroid dose to be about 1490 rads (for a 20 gram thyroid) while the prescribed I-123 would have yielded a thyroid dose of about 21 rads.
The licensee concluded that the amount of radioactivity administered was not dangerous.
+
Cause or Causes - The root cause was the licensee's failure to properly check the dose label with the prescribed dose.
Actions Taken to Prevent Recurrence 1
Licensee - The licensee's corrective actions were to revise procedures to require all I-123 and I-131 doses be assayed in the dose calibrator at both the I-123 ana 1-131 settings.
If the ratios and indicated doses are not compatible, the licensee will recheck with the nuclear pharmacy as to what isotope and dosage had been sent.
Additionally, if any doubt exists as to the proper isotope or dosage, the Radiation Safety Officer is to be consulted before J
proceeding.
NRC - Upon being notified of the event, NRC Region IV requested additional Information; this was received on February 17, 1987.
Region IV conducted a follow-up inspection on March 27, 1987, to obtain additional information and to review proposed corrective actions.
NRC concluded that the root cause of this event was as described above.
The licensee's corrective action was deemed appropriate.
j Evaluations by two NRC medical consultants indicate that while the administered dose was well below the threshold for observing acute effects, there would be a small increased risk of reduction in thyroid function, and a small increased risk of latent thyroid cancer.
This item is considered closed for the purposes of this report.
87-4 Diagnostic Medical Misadministration The following information pertaining to this event is also being reported concurrently in the Federal Register.
Appendix A (see the general criterion) of this report notes that an event involving a moderate or more severe impact on public health or safety can be considered an abnormal occurrence.
/
Date and Place - In a letter dated March 2, 1987, the NRC received written notification that on February 19, 1987 a patient referred to the Nuclear Medicine Department of the University of Massachusetts Medical Center in Worchester, Massachusetts, received a 5.5 millicurie dose of iodine-131 rather than the prescribed 5.0 microcuries.
Nature and Probable Consequences - The misadministration was discovered during a routine review of the doses administered the previous day.
A review of the eveat by the licensee's Radiation Safety Officer showed no defects in the sys-tem used to order, prepare, or administer radiopharmaceuticals in Nuclear Medicine.
The patient's physician clearly requested a 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> uptake study using iodine-131.
Although iodine-123 is routinely used for uptake studies, iodine-131 was prescribed for the convenience of the patient.
A procedure 7
which includes the appropriate dose range is available in the hospital's Proce-dure Manual; however, because of a human error, the nuclear medicine technolo-gist failed to follow the established procedure.
Based upon the 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> uptake and the measured effective half-life, the licensee estimated that the radiation dose to the patient's thyroid was 730 rads and the total body dose was 1.7 rads.
The effect on the thyroid, if any, would be of no importance because prior to the event, the patient was scheduled for a thy-roidectomy to be performed in March.
The licensee has advised the NRC that no adverse effects have been noted nor are any anticipated as a result of the misadministration.
Cause or Causes - The cause was due to human error by a nuclear medicine technologist.
i Action Taken to Prevent Recurrence Licensee - The records of the preparation of each patient dose of iodine-131, diagnostic or therapeutic, will be reviewed and countersigned by the Chief Nuclear Meaicine Technologist or the Clinical Director of Nuclear Medicine prior to administering the dose to the patient.
The technologist involved in the event was cautioned to be more careful in the future.
NRC - The incident is being reviewed by an NRC medicine consultant.
Unless new, significant information becomes available, this item is considered closed for the purposes of this report.
87-5 Significant Breakdown in Management Oversight and Control of Radiation Safety Program at Two of a Licensee's Irradiator Facilities The following information pertaining to this event is also being reported con-I currently in the Federal Register.
Appendix A (see Example 11 of "For All Licensees") of this report notes that a major deficiency in management or pro-cedural controls in major areas can be considered an abnormal occurrence.
Date and Place - On March 17, 1987, the NRC issued a Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $10,000 to Radiation 7
Sterilizers, Inc. of Menlo Park, California (Ref. 4).
Thi. proposed fine repre-sents a 100% escalation for violations found at the licensee's irradiator i
facilities in Schaumburg, Illinois and Westerville, Ohio.
Some of the violations related to unsafe practices which could have resulted in serious overexposure of licensee personnel.
Nature and Probable Consequences - On January 14, 1987 and January 27, 1987, unannounced, routine safety inspections were performed by the NRC at the licensee's Schaumburg and Westerville facilities.
The licensee uses sealed sources in pool type irradiators to sterilize medical products.
At the time of the inspections, the Schaumburg facility possessed about 2.5 million curies of colbalt-60 and the Westerville irradiator was loaded with 8.4 million curies of cesium-137.
8
i l
i I
During the inspections at the.two facilities, the NRC inspectors identified numerous violations of NRC requirements, including:. (1) failure to test smoke i
and temperature alarms at required intervals; (2)-failure to maintain an oper-f able warning beacon in the maze entrance to the. gamma cell; (3). failure to main-tain an operable access barrier to the gamma' cell, a situation which could lead to accidental personnel entry; (4) failure to maintain operable control panel water level indication and an operable system to detect and shut down the irradiator in the event of source storage pool excessive water loss; (5). failure to make a thorough visual check of the entire gamma cell before exposing.the source; (6) failure.to use personal identification tags for' access control as required; (7) failure to maintain a seismic detector in an operable condition, and (8) failure to post an emergency telephone call list in the control room.
[As discussed further below, Items (3) and (7) were later de'eted from the list' i
of violations, and the civil penalty reduced accordingly.]
Two of the violations at the Schaumburg facility (i.e., failure to test'the i
gamma cell smoke and temperature alarms and failure.to maintain an' operable warning beacon at the entrance to the irradiator area).were repeat violations which had been previously identified during an inspection in March 1985.
Following.each of the inspections, Region III sent a Confirmatory Action Letter to the licensee confirming corrective actions which either had already been taken, or were to be taken by the licensee.
The Confirmatory Action Letters I
were issued on January 16, 1987 and February 4, 1987, for the Schaumburg facility (Ref. 5) and Westerville facility (Ref. 6), respectively.
On February 12, 1987, NRC Region III forwarded the inspection findings to the licensee (Ref. 7).
While there were no actual instances of licensee personnel-receiving radiation exposures as a result of the violations found, the unsafe practices subjected.
the personnel to an unnecessary increased risk of such exposures.
Cause or Causes - The causes of the violations were. generally attributed to a breakdown in the management control and oversight of the radiation safety pro-gram at the two facilities.
Equipment was not properly maintained and safety procedures were not consistently followed.
Actions'Taken To Prevent Recurrence Licensee - The licensee has repaired the affected equipment, revised its operat-ing procedures, and retrained its personnel to assure compliance with the NRC regulations.
NRC - As previously mentioned, on March 17, 1987, the NRC forwarded to'the iTcensee a Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $10,000 for the violations found'(Ref. 4).
The base civil penalty for the violations would be $5,000.
However, this was increased by 100 percent because of: (1) the licensee's prior knowledge of the problems, (2) the licensee's failure to take prompt and effective corrective measures for pre-viously identified violations, and.(3) the' duration of some of the: violations (some had existed for several months).
The licensee protested the proposed fine and disagreed with some of the inspection findings.
Upon review, the NRC staff determined that two'of the eight violations originally cited did not occur. -These two were the failure 9
to maintain an operable access barrier to the gamma cell (the defective door was promptly repaired when it was discovered to be inoperable) and the failure to maintain a seismic detector in an operable condition (the detector was not re-quired in the NRC license).
The fine was reduced to $7,500 and an Order Impos-ing Civil Penalty was issued to the licensee on August 18, 1987.
The NRC will perform further inspections to review the adequacy of the licensee's corrective actions.
(Note:
0n June 1, 1987, the State of Illinois assumed regulatory authority over the users of byproduct material in the State of Illinois, including the Radiation Sterilizer facility in Schaumburg, Illinois.
Subsequent inspections of that facility will be conducted by the Illinois Department of Nuclear Safety.)
Unless new, significant information becomes available, this item is considered closed for the purpose of this report.
87-6 Diagnostic Medical Misadministration The following information pertaining to this event is also being reported concurrently in the Federal Register.
Appendix A (see the general criterion) of this report notes that ari event involving a moderate or more severe impact on public health or safety can be considered an abnormal occurrence.
Date and Place - On April 27, 1987, NRC Region IV was notified by Veterans Administration Medical Center, Boise, Idaho, that on April 1, 1987, 400 micro-curies of I-131 was administered to an adult male for a total body scan; on April 6, 1987, it was discovered that a hone scan using technetium-99m was the desired study.
Nature and Probable Consequences - On April 1, 1987, based only on telephone information without having authorization forms which would indicate the specific procedure desired by the prescribing physician, the licensee's nuclear medical staff proceeded with the total body scan procedure using 400 microcuries of I-131.
On April 6, 1987, an evaluation of the scan indicated that the radioac-tive isotope and dosage were inappropriate for the scan desired.
The desired study was a bone scan using technetium-99m.
The licensee calculated that the patient received a whole bcdy and thyroid dose of about 0.47 and 400 rads, respectively.
The physician user evaluated the exposure and concluded that the irradiation posed a small, but still significant, risk of reduction in thyroid function.
The patient will be recommended by the licensee for long term follow-up by'a qualified physician.
The risk of eventual thyroid cancer is small but cannot be discounted.
Cause or Causes - The cause was due to the nuclear medical staff proceeding with a procedure on the basis of telephone ir, formation, without having authorization forms to verify the procedure desired.
Actions Taken to Prevent Recurrence Licensee - lhe licensee's investigative conmittee made the following recommenda-tions that will be implemented: the physician-user will review each case prior l
l 10
to the staff proceeding with the procedure; appropriate forms will be provided to the nuclear medical staff before they start a procedure; deviations from the dosages listed in the Nuclear Medicine Procedure Manual will not occur unless authorized by the physician-user; and the physician-user will review the pro-cedures manual and operating policies with his technical and clerical staff.
NRC - Region IV conducted a follow-up inspection at the licensee's facility on May 19, 1987, to obtain additional information concerning the incident and to review proposed corrective actions.
The inspector considered the corrective actions to be appropriate.
This item is considered closed for the purposes of this report.
87-7 Significant Breakdown in Management Oversight and Control of Radiation Safety Program at an Industrial Radiography Licensee The following information pertaining to this event is also being reported con-currently in the Federal Register.
Appendix A (see Example 11 of "For All Licensees") of this report notes that a major deficiency in management or pro-cedural controls in major areas can be considered an abnormal occurrence.
Date and Place - On April 1, 1907, the NRC issued a Demand for Information and Notice of Violation and Proposed Imposition of Civil Penalties to Grede Foun-dries, Inc., Milwaukee, Wisconsin (Ref. 8).
This action was taken after an October 1986 inspection showed a significant breakdown in the licensee's over-sight and control of its radiation safety program.
Nature and Probable Consequences - The company's NRC license stipulates that only individuals who have passed an approved training program and whose name has been added to the license may work alone as a radiographer.
The NRC con-ducted the October 1986 inspection to review the circumstances surrounding mis-leading statements made by Grede Foundries in letters to the NRC on June 5 and September 11, 1986.
In the letters, Grede requested that its license be amended to add an additional person to the license as an authorized radiographer.
The June 5 letter stated that the individual had been a radiographer at another company, had taken and passed the Magnaflux Quality Services Radiation Safety and Control Program, and had passed the licensee's Emergency Procedures Test.
The NRC learned, however, that the individual had not been listed as a radiog-rapher at her previous place of employment, as Grede had stated.
A deficiency letter dated August 14, 1986 was then sent to the licensee from the NRC's Region III office requesting documentation of the individuals Magnaflux training and confirmation that she had been instructed in the licensee's operating and emergency procedures and had demonstrated competence in the use of the licensee's radiographic devices.
The licensee's September 11, 1986 response included a copy of a test taken by the alleged radiographer, entitled Radiation Safety Control Program - Assistant Radiographer Examination." The word " assistant" was crossed out.
The NRC then conducted a special safety inspection on October 8, 9, 27, and 28, 1986, to review the validity of the information supplied by Grede, concluding that the Radiation Safety Officer (R50) was not familiar with NRC requirements for the training of radiographer.
The RSO believed the same test could be 11
given to both an assistant radiographer and radiographer.
And since he was requesting a radiographer be added to the license, he lined out the word
" assistant" on the test.
However, examinations for assistants and radiographer are different.
The NRC concluded that the licensee had submitted inaccurate information.
Further, it was determined that the unqualified / untrained radiographer made 43 radiographic exposures on August 6, 7, and 8, 1986, which was in violation of NRC requirements and contrary to the conditions of Grede's license.
In addition, the individual made the exposures with the knowledge of an authorized radiog-rapher, who in turn entered the information into a log and signed off on it as though he had made the exposures himself.
The inspection findings (Ref. 9) were discussed with the licensee on October 28, 1986, and at an enforcement conference held at the Region III Office on November 20, 1986.
In addressing the violations, the licensee acknowledged the facts as presented and discussed corrective actions to prevent recurrence.
On April 1, 1987, the NRC issued the previously mentioned Demand for Information and Notice of Violation and Proposed Imposition of Civil Penalties.
The Demand for Information required the licensee to submit, under oath, actions to be taken or will take to prevent a recurrence of the violations.
The proposed civil penalty was for $7,500, which represented a 50% escalation because of the multiple examples of unauthorized radiographer exposures.
Cause or Causes - The root cause was a lack of regard for and adherence to procedures, and a lack of management control and supervision over licensed activities.
Actions Taken to Prevent Recurrence Licensee - On April 14, 1987, the licensee paid the civil penalty in full, and presented a corrective action program.
On April 24, 1987, the licensee amended its April 14, 1987 response and provided additional information.
The corrective action program implemented specifies that:
no one may enter the radiographic facility unless he or she is listed on the company's NRC license; all repairs to the building, and all moving of castings or other material in or out of the facility will be supervised or monitored by a licensed radiographer; the daily log will include the signatures of only those radiographer who actually per-formed the work; and finally, individuals performing radiography must meet all license requirements, including formal training in Radiation Health Physics.
NRC - The NRC carefully considered the licensee's response and in a letter to the licensee dated May 7, 1987 (Ref. 10) stated that it was determined that no further enforcement actions need be taken at this time if the corrective actions are implemented and continued as described in the licensee's response.
Region III will continue to closely monitor licensee performance.
This item is considered closed for the purpose of this report.
12
s n
/
87-8 Significant Breakdown of Management Controls for Radiographic Operations The following information pertaining to this event is also being reported concurrently in the Federal Register.
Appendix A (see Example 11 of "For All Licensees") of this feport notes that serious deficiency in management or procedural controls in major areas can be considered an abnormal occurrence.
Date and Place - On April 10, 1987, the NRC issued an Order Temporarily Suspend-ing License (Effective Immediately) and Order to Show Cause why the license should not be revoked to A-1 Inspection, Incorporated of Evanston, Wyoming (Ref. 11).
The Order was based on NRC inspections which identified two instances where the licensee permitted unauthorized individuals to conduct radiography.
In one instance, the licensee stated to an NRC inspector that he had not employed such individuals to conduct radiography while later he admitted to an investi-gator that he had.
These actions indicated a disregard for requirements and lack of reasor,able assurance that the licensee could be trusted in the future.
Nature and Probable Consequences - A-1 Inspection, Incorporated has been licensed to possess and use iridium-192 sources of up to 100 curies per source in industrial radiography and replacement of sources in accordance with the conditions specified therein, since May 2, 1984.
The events leading to issuance of the Order first came to light during a routine inspection in December 1984.
The inspector discovered that the licensee had permitted the performance of radiography by an unauthorized individual, who, in so doing, received a whole body exposure in excess of that permitted by regulatory requirements.
On February 28, 1985, Region IV issued a Notice of Violation and Proposed Imposition of Civil Penalty (Ref. 12).
By letter (Ref.
- 13) dated March 21, 1985, the licensee responded to the Notice of Violation, in which it was admitted that an individual not specifically named on the licensee had been allowed to act as a radiographer, explaining that there was not enough time during his employment to add this individual to the license.
The licensee also stated that it would not employ anyone in the future until approved by the NRC and added to the license.
On March 26, 1985, the licensee paid the proposed civil penalty.
Subsequent to the above-described enforcement action, it was alleged to NRC that the licensee had again employed unauthorized personnel to conduct radiographic operations at the Shute Creek Job Site.
On February 27, 1986, licensee manage-ment responded "no" to an NRC Region IV inspector who asked if the licensee i
presently had or ever had in the past employed such individuals to conduct radiography at the LaBarge or Shute Creek areas of Wyoming.
To the contrary, on March 18, 1987, the licensee management admitted in a written statement to an NRC investigator that it had employed such an individual in the subject area to work as an assistant radiographer and had allowed that individual to indepen-dently conduct radiographic operations (i.e., function as a radiographer) on November 18-19, 1985.
The licensee's actions in attempting to deceive the NRC regarding whether it nad utilized the radiographer and in disregarding requirements demonstrate that it is either unable or unwilling to comply with Commission requirements.
Con-tinued conduct of licensed activities could pose a threat to the health and safety of the public.
13
Cause or Causes - The root cause can be attributed to a serious breakdown in the licensee's management controls.
Actions Taken to Prevent Recurrence Licensee - On April 27, 1987, the licensee responded to the requirements of the Order.
NRC - The licensee's response to the Order is still under review.by the NRC staff.
Future reports will be made as appropriate.
AGREEMENT STATE LICENSEES Procedures have been developed for the Agreement States to screen unscheduled incidents or events using the same criteria as the NRC (See Appendix A) and report the events to the NRC for inclusion in this report.
During the first calendar quarter of 1987, the Agreement States reported the following abnormal occurrences to the NRC.
AS87-1 Breakdown in Management and Procedural Controls at an Industrial Radiography Licensee Appendix A (see Example 11 of "For All Licensees") of this report notes that a serious deficiency in management or procedural controls in major areas can be considered an abnormal occurrence.
l Date and Place - On February 17, 1987, the Arizona Radiation Regulatory Agency l
(State Agency) issued an order to U.S. Testing Company, Unitech Services Group, San Leandro, California, to cease all radiographic operations within the state of Arizona.
Nature and Probable Consequences - The order was issued based on the findings i
of an inspection performed on February 6 and 7, 1987, to investigate the cir-cumstances associated with two employees (a radiographer and an assistant radiographer) of the licensee receiving radiation exposures in excess of regulatory limits while performing radiographic operations at the Navajo Generating Station, Page, Arizona.
The inspection results are described below.
The radiographer and assistant began the radiography evaluation at approximately 10:00 p.m. on February 5, 1987.
They completed shooting a 4-inch Hammond valve at approximately 12:00 midnight, and moved into the penthouse to begin shooting reheat pendants.
It appeared that the two survey meters and the camera were in good working order at that time.
At the time, the camera contained a 103.5 curie iridium-192 source.
During this series of exposures, the radiographer (who had previously been cranking the source in and out) asked the assistant radiographer if he would like to crank the source in and out to give him a break from the routine.
This would also allow the radiographer to perform set-up of the source and film around the super-heat piping welds.
14 l
J e
p l
l 3
f\\
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1
'l During one of the exposures, the assistant cranked the source out, pgforred a, one-minute exposure and cranked the source in.
The assistant radio phphJe then
(
approached the camera with the survey meter and the crank handle in his hands.
The radiographer also approached the area after the source was cranked back in and asked the assistant if everytPing was all.right.
The assistant stated that >
themeterwasreadingzeroasthe)2.pproachedthdcamara.,Theassistantqddiog-ource tube, and the meter was st raphergotuptothecamera,survtyedthf,j reading zero.
g,
.i The radiographer removed the film from Are we y area, and as he was doing so the assistant radiographer experienced diffitfity locking the camera.
The assistant asked the radiographer how to lock the camera and he stated that you just turn the knob on the end.
The assistant stated the cangn would still not lock.
The
>(
radiographer asked the,1ssistant radiographer what tie survey meter read.
He stated the meter still read zero and the radiographer told him to place it up ',.f p
against the camera and take another reading.
The assistant stated that the
\\
survey meter was still readir g zero ati t, hat time, and the Ndisgrapher instructed i
him to take it to the Battery Cceck Ptgition.
At that psith,l the %ter would still not function and the radiograpbw said they should both immediately leave.
9 1
The radiographer retreated back to'where the Wrece was cranked out', and checked l
their pocket dosimeters.
Both p cket dosimeters (2B M ) were off sca.e radiographer then crawled up to the crank assesbly a'r.d turned the crank M(The i
k a,
He was then able to crdk the souh:e back in approximately, a e'@r.
and forth.
The camera was locked and the radiographer went tcQ/)tify to one-full turn.
their night supervisor.
The Phrit Mervisor for U.S. Testing was then'notHind q\\
by phone.
i t
/
It should be noted that the radiographer hcocoriq Mally planned to use a GE
,6
/
s Smith and Associates Model GS-109 Mrvey meter, Serial No'. 3326, calibrated on Of January 23, 1987.
However, they stated that this survey meter was nct function-
}l ing on the times-one scale, so they left the survey,. meter at the manway to the b
penthouse, approximately 6 to 10 feet frmt where thf ca nk assembly was bcated for this shot.
The radiographer then usd a Victoreen survey veter, Model s
492, Serial No.1732 that either failed while the radtgrapher was approaching < 'i N,
the camera, or saturated after the assistant radiographer reached the camera. ',
Upon inspecting the meter it was noted that it was calibrated on January 23, i
1987, and was due for calibration on April.23,1987.
The meter was not func-r tioning at the time of the inspection, and,the meter was taken to the site i
f>
electronic shop and the batteries tested at 1-1/2 valts each.
The meter would
/
not function on the Battery Test Position even with the batteriu still in good j'
condition.
i, f f The personnel that the company Radiation Safety Officer (RS0) had authorij p to be radiographer at the site were not those actually involved in the event ~.
One of the authorized individuals was the Acting Plant Manag@ for U.S. Testing at the time of the incident, and the other was not on site,et that time.
The
/
U.S. Testing Acting P.lant Manager had instructed the ass \\stantiradiographer to assist the radiographer with radiography on the evening of February 5,1987.
The assistant stated to the State Agency inspector that he had not received ar)y additional training prior to the incident.
The radiographer stated thd he l
{;
could not remember the last time he had received training.
Theradiohapher j
L possessed a certificatim card from U.S. Testing stating that he Lag qualifiedi s
i i g
15
' f i ';.s-N >
~
i t'
r f
c i
as a LeveT JI Radiographer on August 11,- 1.986.
This card stated that he had been examined in accordance with "SNT"7C-1A."
The crank assembly for the camera was 2.iMeet long and the source tube being utilized at the time of tip incident was seven feet inng.
One turn on the crank assembly was measured to sve the drive cable approxiriately 8-1/2 inches.
The
' body of the camera id 10 inches across, and the length of the S-tube within the j
camera is estimated t'o be approximately 12 inches.
This would mean that the source itsel f wars pcsitioned approximately six inches along the S-tube in the
,1 7 <
shielded position',tand 1/2 to one-full turn of 4he crank assembly would move the source an additional 4-1/4 to 8-1/2 inches, positioning the source right in the vicinity of the source tube connection just at the exterior of the camera body.
I A reenactment of the incident was made and measurements were taken from the radiographer' film badge locations to major portions of their bodies.
The radiographer film badge indicated that;he had received 3100 millirems; however, based on the proximity of his upper trunk, head and eyes to the source compared to the film badge location, the whole body exposure could have been as high as 16.9 rem.
Calculations for the assistant radiographer indicated that his right hand and forearm could have received 850 millirem in addition to his 2,650 milli-rom whole body exposure.
It was determined during the reenactment that the as,istant's film badge exposure gave a very good representation of his actual whole.Mdy exposure.
> The Statt Agency's inveAt'gation >rdvealed a number of concerns regarding the
'$censee'sma.ugemeniandprocedMicontrolstoassurecompliancewiththe Ap.mcy's rules and Titmse conditions.
Contrary to the rules and license con-ditions for perforrrh t radio 0 apher procedures in Arizena, the credentials, 6
training and experience records for the newly appointed R50, the radiographer, and the assistant radiographer had not been submitted to the State Agency for evaluation and approval.
One of,the contributing factors for the overexposure was the failure of the licenseb;:0 properly train the assistant radiographer.
Therefore, on Februmy 17, 1987, the State Agency directed the licensee to cease any further radiogru5ic procedures within the state of Arizona until the licensee submitted. ;'nd the State Agency approved, documentation which corrected the discrepancio.
Dr. March 9, 1987, thrt State Agency sent to the licensee a lettar of non-cocpliance and proposed civil panalty in the amount of $17,000.
Cause or Causes - The root cause was a bre'akdown in ' management and procedural controls.
This was a contributing cause of the overexposure experienced.
Actions Taken to Prevent Recurrence i
Licensee - Tin licensee terminated radiographic operations in Arizona as directed.
T h licenseesjubmitted training and experience records to the State Agency for g
the RSO and frrethe radiographer they proposed for work within the state.
The 7?censee alf,n 'eached agreement with the State Agency to pay the civil penalty r
inthreeinstafmentsnerathreemonthperiod.
StateAgency-l1hadditiontotheactionspreviouslydiscesed,onMarch16, 1987, the Agency sent a letter to the licensee stating that the licensee could resume radiographic operations within the state with eight named radiographer allowed tq perform radiographic procedures, s
16 4
T Unless ned, significant information becoms available, this item is considered i
closed for the purposes of this report, v
Editor's Note:
The licensee has performed work (including work under licenses istued by the NRC and various Agreement States) for nut,erous clients in'various 1
states.
The NRC has identified potential problems relating to licensee manage-rnnt and procedural controls at some sites.
The extent of the problem is aider investigation by the NRC and if the findings warrant, the results will i
ba repo"Rd in a. succeeding quarterly abnormal occurrence report to Congress.
]
AS87-2 Breakdown in Manag ment and Procedural Controls at an Industrial RadiographQgnsee Appendix A (see Example 11 of "For All Licensee") of this : aport notes that a y
serious deficiency in management or procedural controls in major areas can be i
considered an abnormal occurrence.
j Date and Place - On February 27, 1987, an Emergency Order suspending all radiog-raphic operations was issued by an inspector for the California Department of Industrial Relations to Continental Testing and Inspection (CTI), Signal Hill, California.
J Nature and Probsole Consequences - During a routine compliance inspection of CTI's licensed radiog7aphic ope 7ations conducted by the Califernia Department
~
of Industrial Relations, working unter contract with the California Department of Health Services' Radiolog'ic, Health Branch, it was detertained that individuals acting as radiographer may nave lacked the required traiMng and experience.
The radioactive material license issued to CTI permitted the Radiation Safety Officer (RS0) to designate individuals meeting the Department's minimum stan-j dards to act as radiographer.
The licensee was required to maintain records documenting the qualifying criteria and the qualification of persons authorized to perform radiography.
Records required for each person included a statement of training and experience, a certification of satisfactorily completing a radia-tion safety training course (approved by the Department), a copy of results of field audits and written examinations, and a certification from the RSO that the radiographer had met the requirements established in Departmental Regulations relative to required training and experience prior to their acting as a radiog-rapher or radiographer's assistant.
Records which would substantiate that ir.dividuals. acting as radiographer had received training and experience considered by the Department to be a minimum standard were not available for inspection.
Therefore, pursuant to Californie.
Health and Safety Code Section 25603, and to assure health and safety of workers and the general public, an Emergency Orc'er was issued by the inspector and all CTI radiographic crews were required to ieSediately cease cperations.
On March 2, 1987, a Departmental Order confirmed the order issued by the-inspector.
17 l
/
The inspection also identified an overexposure during the first quarter of 1987.
During the quarter an individual acting as a radiographer's assistant received an exposure of 2000 millirem to the whole body.
Cause or Causes - The root cause was a breakdown in management and procedural controls.
Actions Taken to Prevent Recurrence 1
Licensee - As directed, the licensee ceased operations.
The licensee proposed l
six individuals be authorized to perform radiography.
State Agency - On March 9, 1987 the Department modified the radioactive material 4
license issutd to CTI so that all radiographic operations be conducted only by i
individuals specifically authorized by the Department.
The amendment issued on March 9, 1987 authorized four individuals to act as radiographer and rescinded the Emergency Order.
l In regard to the overexposure during the first quarter of.1987, the Agency determined it was caused by human error and failure to perform required sur-veys.
The Agency issued a Notice of Violation; the licensee has not yet resoonded to the Notice, out has removed the individual from working with.
radioact1ve sources for three months.
On May 15, 1987 the Agency was informed that another radiographer's assistant had exceeded the quarter 1. dose limits.
This individual received 1300 millirem 3
i for the second quarter of 1987 and has been removed from working with sources of radiation for three months.
This overexposure is being investigated and to date r.o Notice of Violation has been issued.
The investigation into the operations of CTI is continuing and escalated enforcement actions are being considered.
Unless new, significant information becomes available, this item is considered closed for the purposes of this report.
18
REFERENCES 1.
Letter from Victor Stello, Jr., NRC Executive Director for Operations, to J. C. Everett, III, Chairman of the Board and Chief Executive Officer, Philadelphia Electric Company, forwarding an " Order Suspending Power Operation and Order to Show Cause (Effective Immediately," Docket Nos.
50-277 and 50-278, March 31, 1981
- 2.
Letter from Thomas E. Murley, Regional Administrator, NRC Region I, to Mr. S. Daltroff, Vice President, Electric Production, Philadelphia l
Electric Co., forwarding a Notice of Violation and Proposed Imposition of Civil Penalty, Docket No. 50-278, June 9, 1986.*
3.
U.S. Nuclear Regulatory Commission, NRC Information Notice No. 87-21,
" Shutdown Order Issued Because Licensed Operators Asleep While on Duty,"
May 11, 1987.*
4.
Letter from A. Bert Davis, Acting Regional Administrator, NRC Region III, to Allan Chin, President and Corporate Radiation Safety Officer, Radiation Sterilizers,-Inc., forwarding a Notice of Violation and Proposed Imposi-tion of Civil Penalty, Docket No. 30-19025, March 17, 1987.*
5.
Confirmatory Action Letter from James G. Keppler, Regional Administrator, NRC Region III, to Allan Chin, President, Radiation Sterilizers, Inc.,
License No. 04-19644-01, January 16, 1987.*
6.
Confirmatory Action Letter from James G. Keppler, Regional Administrator, NRC Region III,'to Allan Chin, President, Radiation Sterilizers, Inc.,
License No. 04-19644-01, February 4, 1987.*
7.
Letter from Jack A. Hind, Director, Division of Radiation Safety and Safeguards, NRC Region III, to Allan Chin, President, Radiation Sterili-l zers, Inc., forwarding Inspection Report No. 30-19025/87-01, License No.
04-19644-01, February 12, 1987.*
8.
Letter from James M. Taylor, Director, NRC Office of Inspection and Enforcement, to William Irvine, Vice President, Grede Foundries, Inc.,
i forwarding a) a Demand for Information, and b) a Notice of Violation and l
Proposed Imposition of Civil Penaltie's, Docket No. 30-06728, A, il 1, j
1987.*
j 5
l 9.
Letter fran Jack A. Hind, Director, Divison of Radiation Safety and Safeguards, NRC Region III, to Bipin Shah, Technical Director, Grede Fouridries, Inc., forwarding Inspection Report No. 30-06728/86-02, Docket No. 30-06728, November 25, 1986.*
10.
Letter from James M. Taylor, NRC Deputy Executive Director for Regional i
Operations, to William Irvine, Vice President, Grede Foundries, Inc.,
Docket No. 30-06728, May 7, 1987.*
1
- Available in NRC Public Document Room, 1717 H Street, N.W., Washington, DC 20555, for public inspection and/or copying.
19 L
I 11.
Letter from James M. Taylor, Director, NRC Office of Inspection and Enforcement, to G. W. Wyrick, President, A-1 Inspection, Inc. forwarding Order Temporarily Suspending License (Effective Immediately) and Order to Show Cause, License No. 49-21496-01, Docket No. 30-20866, April 10, 1987.*
12.
Letter from Robert D. Martin, Regional Administrator, NRC Region IV, to G. W. Wyrick, President, A-1 Inspection, Inc., forwarding Notice of Violation and Proposed Imposit-ion of Civil Penalty, License No.
49-21496-01, Docket No. 30-20866, February 28, 1985.*
13.
Letter from Gary W. Wyrick, President, A-1 Inspection Inc., to Robert D.
Martin, Regional Administrator, NRC Region IV, License No. 49-21496-01, Docket No. 30-20866, March 21, 1985.*
l i
i l
1
- Available in NRC Public Document Room, 1717 H Street, N.W. Washington, DC 20555, for public inspection and/or ccpying.
20
1 APPENDIX A ABNORMAL OCCURRENCE CRITERIA The fullowing criteria for this report's abnormal occurrence determinations were set forth in an NRC policy statement published in the Federal Register on February 24, 1977 (Vol. 42, No. 37, pages 10950-10952).
An event will be considered an abnormal occurrence if it involves a major re-duction in the degree of protection of the public health or safety.
Such an event would involve a moderate or more severe impact on the public health or safety and could include but need not be limited to:
1.
Moderate exposure to, or release of, radioactive material licensed by or otherwise regulated by the Commission; 2.
Major degradation of essential safety-related equipment; or 3.
Major deficiencies in design, construction, use of, or management controls for licensed f acilities or material.
Examples of the types of events that are evaluated in detail using these crite-ria are:
For All Licensees 1.
Exposure of the whole body of any individual to 25 rems or more of radia-tion; exposure of the skin of the whole body of any individual to 150 rems or more of radiation; or exposure of the feet, ankles, hands or forearms of any individual to 375 rems or more of radiation (10 CFR S20.403(a)(1)),
or equivalent exposures from internal sources.
2.
An exposure to an individual in an unrestricted area such that the whole-body dose received exceeds 0.5 rem in one calendar year (10 CFR 620.105(a)).
3.
The release of radioactive material to an unrestricted area in concentra-tions which, if averaged over a period of 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />, exceed 500 times the regulatory limit of Appendix B, Table II,10 CFR Part' 20 (10 CFR 620.403(b)).
4.
Radiation or contamination levels in excess of design values on packages, or loss of confinement of radioactive material such as (a) a radiation dose rate of 1,000 mrem per hour three feet from the surface of a package containing the radioactive material, or (b) release of-radioactive mate-rial from a package in amounts greater than the regulatory limit.
5.
Any loss of licensed material in such quantities and under such circum-stances that substantial hazard may result to persons in unrestricted.
areas.
6.
A substantiated case of actual or attempted theft or diversion of licensed material or sabotage of a facility.
21 J
7.
Any substantiated loss of special nuclear material or any-substantiated inventory discrepancy which is judged to be significant relative to nor-mally expected performance and which is judged to be caused by; theft or diversion or by substantial breakdown of the accountability system.
8.
Any substantial breakdown of physical security or material control (i.e.,
access control, containment, or accountability systems) that significantly weakened the protection against theft, diversion, or sabotage.
9.
An accidental criticality (10 CFR 670.52(a)).
10.
A major deficiency in design, construction, or operation having safety implications requiring immediate remedial action.
11.
Serious deficiency in management or procedural controls in major areas.
12.
Series of events (where individual events are not of major importance),
recurring incidents, and incidents with implications for similar facili-ties (generic incidents), which create major safety concern.
For Commercial Nuclear Power Plants 1.
Exceeding a safety limit of license technical specifications (10 CFR S50.36(c)).
2.
Major degradation of fuel integrity, primary coolant pressure boundary, or primary containment boundary.
3.
Loss of plant capability to perform essential safety functions such that a potential release of radioactivity in excess of 10.CFR Part 100 guidelines could result from a postulated transient or accident (e.g., loss of emer-gency core cooling system, loss of control rod system).
4.
Discovery of a major condition not specifically considered in the safety analysis report (SAR) or technical specifications that requires immediate remedial action.
1 5.
Personnel error or procedural deficiencies which result in loss of plant capability to perform essential safety functions such that a potential release ~of radioactivity in excess of 10 CFR Part 100 guidelines could result from a postulated transient or accident (e.g., loss'of emergency core cooling system, loss of control rod system).
For Fuel Cycle-Licensees.
j 1.
A safety limit of license technical specifications is exceeded and a plant shutdown is required (10 CFR 650.36(c)).
2.
A major condition not specifically considered in the safety analysis re-port or technical specifications that requires immediate remedial' action.
3.
An event which seriously compromised the ability of a confinement system to perform its designated function.
22
APPENDIX B UPDATE OF PREVIOUSLY REPORTED ABNORMAL OCCURRENCES During the January through March 1987 period, the NRC, NRC licensees, Agreement States, Agreement State Licensees, and other involved parties, such as reactor vendors and architects and engineers, continued with the implementation of actions necessary to prevent recurrence of previously reported abnormal occur-The referenced. Congressional abnormal occurrence reports below provide rences.
the initial and any updating information on the abnormal occurrences discussed.
The updating provided generally covers events which took place during the report period, thus some information is not current.
Some updating, however, is more current as indicated by the associated event dates.
Open items will be discussed in subsequent reports in the series.
NUCLEAR POWER PLANTS 79-3 Nuclear Accident at Three Mile Island This abnormal occurrence was originally reported in NUREG-0090, Vol 2, No. 1,
" Report to Congress on Abnormal Occurrences:
January-March 1979," and udpated in each subsequent report in this series, i.e., NUREG-0090, Vol. 2, No. 2 through Vol. 9, No. 4.
It is further updated for this report period as follows.
Reactor Building Entries During the first calendar quarter of 1987, 89 entries were made into the TMI-2 reactor building, bringing the total number of entries since the March 1979 accident to 1232.
Reactor building activities during this period centered on the continuing defueling operation, including:
data acquisition; video inspec-tion; bulk defueling; and vacuuming and removal of standing partial peripheral fuel assemblies.
Reactor vessel water clarity was significantly improved.
The last reactor internals vent valve was also removed to provide improved access to the reactor vessel lower head.
Reactor Vessel Defueling Operations At the start of the calendar year 1987, the licensee was in the process of removing the drilled "hard crust" area using existing and modified tooling.
The spade bucket tool was moderately successful, achieving a fill rate of approxi-mately one fuel canister per two days.
Some pieces were too large to load into the canisters and had to be set aside.
A long-handled chisel driven by a.300 lb.
sliding weight was unsuccessful at breaking these rocks apart.
Other techniques such as the air-operated chisel and the cavitating water jet are now being evaluated.
The water clarity within the reactor vessel was improved through the addition of an organic polymer coagulant to the reactor coolant system.
Water was then filtered through diatomaceous earth followed by filtration through canisters in the Defueling Water Cleanup System.
This method was based on tests in late December showing that coagulants would allow the filter canisters to remove organic and inorganic particles from the water without rapidly clogging.
A single filter canister processed nearly 500,000 gallons of coolant using this 23
method.
This level of filtration permits the turbidity level in the reactor vessel to be quickly reduced as required to support defueling operatior.s.
At the end of January 1987, an air lift tool was placed in operation to vacuum up smaller loose debris.
The tool uses suction to lift water and debris up a 4-inch diameter nozzle to a baffle, which separates out heavier debris and j
directs it into a fuel canister.
The air lift succeeded in loading approximately 2500 lb. of debris.
Because most easily accessible loose debris has now been removed, modifications to the tool for future use are being evaluated.
Between February 9 and 23, defueling operations were suspended while the last reactor internal vent valve was removed and an extensive data acquisition program surveyed various regions of the reactor vessel and adjoining reactor coolant system components.
The video inspections showed that significant amounts of core debris lie between the baffle plates and the core barrel.
Other inspections in the reactor vessel showed resolidified material in the northwest quadrant of the lower core support assembly (CSA), as well as a partially melted incore instrument quide tube in the southeastern reactor vessel lower head region.
The resolidified material is similar to that seen during previous video inspection in the southeast quadrant of the lower CSA structure.
The large quantity of fine debris seen in the lower head apparently resulted from the core drilling i
operations in the summer.
Defueling operations for the remainder of the first calendar quarter of 1987 i
I centered on removing the peripheral standing fuel assemblies using a variety of snaring, clamping, and cutting tools.
The assemblies were then loaded into fuel canisters.
On March 18, defueling operations were able to successfully remove one essentially intact peripheral assembly, A-7.
The next day a second
)
intact assembly, A-6, was removed.
Video surveys _were made of the resulting I
hole.
Although debris partially refilled the hole later, the hole can provide a potential access to allow removal of adjacent stub fuel assemblies by jacking them up from the lower end fittings.
l Defueling activities through March 1987 have resulted in the removal of approxi-mately 27 percent (80,000 lbs) of the total estimated TMI-2 core debris.
To i
evaluate the techniques and tools planned for use in future defueling operations, nine task groups were established.
The task groups addressed the areas of:
debris and rock removal; fuel stub end removal; Westinghouse vacuum system; air-lift; core support assembly cutting; bottom head vacuuming; bottom head defueling of non-vacuumable material; core former wall defueling; and extended vessel l
defueling.
Each group will issue a report summarizing its conclusions and I
recommendations.
The licensee will use these reports to re-evaluate its current l
schedule for completion of defueling operations.
EPICOR II/ Submerged Demineralized System (SDS) Processing l
l Through March 1987, a total of 4,443,614 gallons of water have been processed I.
through the SDS and a total of 3,315,944 gallons have been processed through the EPICOR II system.
For the reporting period, approximately 80,000 gallons and 65,000 gallons were processed by the SDS and EPICOR II systems, respectively.
24
Cask and Liner Shipments Offsite shipments of TMI-2 core debris to INEL continued during the first calendar quarter of 1987.
Five loaded shipping casks, each holding seven defueling canisters, were transferred by rail during the reporting period.
Through March 1987, approximately 75,000 lbs. of core decris (25% of the total estimated quantity) had been shipped.
Five EPICOR liners and one SDS vessel were also shipped offsite during the reporting period.
Auxiliary and Fuel Handling Building (AFHB) Activities Decontamination activities continued in the TMI-2 AFHB during the first quarter of 1987.
These activities centered around steam vacuum cleaning, scabbling, and hands-on decontamination of AFHB cubicles.
The robot Louie 2 was used to scabble the highly contaminated seal injection valve room.
The initial phase of makeup and purification system flushing was completed and good dose reduction was achieved.
During this quarter, sediment removal began from the' auxiliary build-ing sump using the Chem-Nuclear solidification system.
Through March 1987, two j
liners have been filled and solidified.
A third liner was installed in the Chem-Nuclear system to complete the operation.
Post-Defueling Monitored Storage In submittals dated December 1986 and March 1987, the licensee notified the NRC of its plans for Post-Defueling Monitored Storage (PDMS).
According to these l
submittals, which require NRC approval, the plant will be placed in PDMS upon completion of the cleanup program at TMI-2 and will pose no risk to the health er safety of the public, the workers or the environment.
The licensee, in its proposal for PDMS, has made no decision on its ultimate plans (decommissioning /
recommissioning) for the facility.
During PDMS, the licensee will maintain and monitor the plant under NRC regulations; radioactive waste will have been removed or readied for shipment; and the program for disposal of radioactive water will have been started.
After review of these submittals, the NRC staff will prepare an Environmental Impact Statement.
Proposal to Dispose of Accident-Generated Water On December 29, 1986, the NRC staff issued for comment a draft Supplement No. 2 to NUREG-0683, " Programmatic Environmental Impact Statement" (PEIS) on the issue of the disposal of accident generated water (Ref. B-1).
This draft supplement assesses the environmental consequences of ten disposal alternatives, including the licensee's preferred method, and concludes that no significant impact would result from implementation of any considered alternative.
A public comment period was to follow the issuance of this draft.
At the request of the Commis-sion's TMI-2 Advisory Panel, the comment period was extended 45 days, to a total of 90 days, ending on April 14, 1987 for all commenters.
During the first cal-endar quarter of 1987, the staff discussed the draft with a number of interested environmental organizations and with the Commission's Advisory Panel.
Following the close of the public comment period and consideration of public comment on draft Supplement No. 2, the NRC staff plans to issue the final supple-i ment on accident generated water.
Following issuance of the final supplement, j
the staff will be prepared to take a position on the licensee's request to evap-l orate the Water at the TMI site.
25
TMI 2 Advisory Panel Meeting The Advisory Panel for the Decontamination of Three Mile Island Unit 2 (Panel) met three times during the reporting period.
On January 21, 1987, the Panel met in Lancaster, Pennsylvania.
At tnis meeting, the NRC staff discussed the Draft Environmental Impact Statement on the disposal of accident generated water.
Several individuals from the public spoke before the Panel on issues of concern regarding the proposed water disposal.
On February 26, 1987, the Panel again met in Lancaster, Pennsylvania, At this meeting the NRC and GPU Nuclear staffs responded to questions posed by the Panel.
and the public on the NRC's Draft Environmental Impact Statement for the Disposal of Accident-Generated Water.
The Panel listened to statements by members of the i
public regarding the licensee's proposed disposition of the accident generated water.
On March 25, 1987, the Panel' met at the Holiday Inn, Harrisburg, Pennsylvania.
At this meeting the Panel received presentations on the issue of accident-generated water disposal from Drs. R. Piccioni and E. Sternglass.
The Panel.
also received a number of public comments on the licensee's proposal for the disposal of accident generated water.
The Panel found the NRC staff's draft supplement to the PEIS an acceptable evaluation of alternatives and environ-mental impact.
The Panel voted 5-4, with one abstention to not endorse the licensee's proposed evaporation option for water disposal.
The Panel also voted 10-0 against any discharge'of water to the Susquehanna River.
Future reports will be made as appropriate.
85-7 Loss of Main and Auxiliary Feedwater Systems This abnormal occurrence, which occurred at Davis-Besse on June 9, 1985, was originally reported in NUREG-0090, Vol. 8, No. 2, " Report to Congress on Abnormal Occurrences:
April-June 1985," and updated in NUREG-0090, Vol. 8, No. 3; Vol. 8, No 4; Vol. 9, No. 1; Vol. 9, No. 2, and Vol. 9, No. 3.
In the latter report, the item was closed out with information current through December 1986. -However, it is being reopened, and then reclosed, to discuss the final civil penalty which was imposed on the licensee (Toledo Edison Company).
As previously reported, the NRC staff had proposed a $900,000 fine for violations of NRC requirements associated with the June 9, 1985 event-(Ref. B-2).
Subse-quently, the licensee requested that the proposed fine be mitigated.
The NRC's Enforcement Policy permits mitigation of fines by as much as 50 percent when unusually prompt and extensive corrective actions have been taken.
Based on the actions taken by the licensee, after the fine was imposed as well as be-fore, the' staff determined that mitigation of the fine by 50 percent was appro-priate because the licensee had taken extensive and prompt actions as a result of the event and was aggressive in establishing a long-term, in-depth corrective 26
l action program.
Therefore, on February 12, 1987, the NRC issued an Order Imposing Civil Monetary Penalties in the amount of $450,000 (Ref. B-3).
On March 14, 1987, the licensee paid the civil penalty.
l
.1 This item is considered closed for the purposes of this report.
85-12 Management Control Deficiencies This abnormal occurrence, involving management control deficiencies at the l
LaSalle Nuclear Power Station, was originally reported in NUREG-0090, Vol. 8, No.
3., " Report to Congress on Abnormal Occurrences:
July-September 1985," and updated in Vol. 9, No. 1.
It is further updated as follows.
As originally reported, on November 22, 1985, the Regional. Administrator of N'RC Region III issued a letter to the licensee under 10 CFR S50.54(f) requesting information on the licensee's plans to improve its performance 'in managing its J
maintenance, operations, and modification activities, including the problems identified in a special NRC Task Force review in July 1985 (Ref. B-4).
The licensee developed and implemented programs in response to the November 22, 1985, letter, and the most recent Systematic Assessment of Licensee Performance report, issued March 4, 1987, reviewed the effectiveness of those programs (Ref. B-5).
The report, which covered the period October 1, 1985, through November 15, 1986, showed evidence of improved regulatory performance by the licensee..The four functional areas which received the lowest category rating (Category 3) in the previous report had improved to ratings of Category 2.
These four areas were Operations, Maintenance, Surveillance, and Quality Program and Administrative Controls..The NRC, in transmitting the report to the licensee, noted that while the performance in those areas had improved,.there was a'need for further high levels of management attention to assure that the licensee's actions continued to show positive results.
As noted in the previous apdate on March 19, 1986, a $50,000' fine was proposed by the NRC for a violation occurring in October'1985 in which portions of the' Unit 2 Emergency Core Cooling System were inoperable for a 13-hour period (Ref. B-6).
The licensee paid this fine on April 19, 1986.
This item is considered closed for.the purposes of this report.
86-9 Emergency Core Cooling System Mini-Flow Design Deficiency This abnormal occurrence was originally reported in NUREG-0090, Vol. 9, No. 2,
" Report to Congress.on Abnormal Occurrences:
April-June 1986," and updated in Vol. 9, No. 3.
The first report discussed Bulletin 86-01 (Ref. B-7) which addressed ECCS pumps potentially not having sufficient cooling because a single.
failure could cause mini-flow valves to close while pump. discharge valves are closed and thus remove all pathways for flow through the pumps.
The second 27
report discussed Bulletin 86-03 (Ref. B-8) which addressed ECCS pumps potentially not having sufficient cooling because the mini-flow valves had two conflicting functions, containment isolation vs. ECCS pump cooling, or because a single failure could cause the mini-flow valves to close 'while pump discharge pressures remained too high for flow through the pumps.
In a related matter, the NRC had issued Bulletin 80-18, " Maintenance of Adequate Minimum flow Through Centrifugal Charging Pumps Following Secondary Side High Energy Line Rupture," on July 24, 1980 (Ref. B-9).
NRC inspections reveal that this issue has been satisfactorily addressed at all affected plants with an un-fulfilled commitment for a permanent installation remaining at only one facility (Zion Units 1 and 2).
During the latter half of 1987, the NRC will issue a NUREG report to document these inspection results.
The problem addressed by Bulletin 86-03 involves a possible failure of a non-safety-related air system affecting a safety related cooling system.
The NRC has issued a study of other such failures, " Air Systems Problems at U.S. Light Water Reactors," AE0D/C701 (Ref. B-10).
The NRC issued Information Notice 87-28, " Air Systems Problems at U.S. Light Water Reactors," on June 22, 1987 (Ref. B-11),
announcing the availability of this study.
The study highlights more than two dozen events in which, contrary to licensing assumptions, a safety-related sys-tem was affected as a result of an air system degradation or failure.
In addi-tion, the NRC initiated reconsideration of Generic Issue 43, " Contamination of Instrument Air Lines," as to whether its priority should be raised based on this new information.
Future reports will be made as appropriate.
86-16 Abnormal Cooldown and Depressurization Transient at Catawba Unit 2 l
This abnormal occurrence was originally reported and closed out in NUREG-0090, Vol. 9, No. 3, " Report to Congress on Abnormal Occurrences:
July-September 1986."
It is being reopened to report the following new information.
As previously reported, on November 12, 1986, the NRC Region II office issued a Severity Level III violation and proposed imposition of civil penalty in the amount of $50,000 to the licensee (Ref. B-12).
The first violation pertained to a significant failure in the licensee's design control program and a second violation pertained to the licensee's failure to establish adequate procedures i
for the conduct of the Loss of Control Room Test.
The Regional Administrator emphasized the importance of a complete and thorough review of design changes and the necessity of adequate procedures and procedure adherence.
The licensee responded to this violation in correspondence dated December 12, 1986 (Ref. B-13), in which they stated that the notice of violation had been incorrectly categorized by the NRC as a "cause for significant concern" leading to a Severity Level III violation.
Duke Power's justification for this conclu-sion was that there was no risk to the public health and safety due to this incident.
In addition, the licensee admitted the first violation, but denied that the deficiencies identified in this violation constituted programmatic deficiencies but were isolated failures of the design review process.
Also denied were the first two of three examples of the second violation.
This 28 l
J
correspondence concluded by requesting a reduction in the severity level and remission of the civil penalty that had been imposed.
The NRC, after careful consideration and review of the information provided in I
the licensee's correspondence identified above, concluded that the violations occurred as stated although an amendment to the violation concerning the adequacy of procedures was provided.
Therefore, on April 14, 1987, an Order imposing a l
civil penalty of $50,000 was issued (Ref. B-14).
In a letter to the NRC dated May 11, 1987, the licensee paid the civil penalty but in doing so again stated that they considered the categorization of the event as a Severity Level III inappropriate and that the civil penalty should not be imposed or should be mitigated.
This item is considered closed for the purpose of this report.
j OTHER NRC LICENSEES t
86-6 Breakdown of Management Controls at an Irradiator Facility This abnormal occurrence, which involved Radiation Technology, Incorporated (RTI), Rockaway, New Jersey, was originally reported in NUREG-0090, Vol. 9, i
No. 1, " Report to Congress on Abnormal Occurrences:
January-March 1986," anJ updated in Vol. 9, No. 2.
It is further updated as follows.
From August 1986 through April 1987, there have been 15 inspections of the j
licensee's facilities,13 of which identified no violations of NRC requirements.
The violations identified during the other two inspections were generally caused by failure to follow procedures, but did not indicate a programmatic weakness nor did they compromise public health and safety.
A special Systematic Assess-ment of Licensee Performance (SALP) conducted for the period from August 1986 through February 1987 indicated generally acceptable performance, with improve-ment needed in the areas of procedure adherence, quality assurance, and plant maintenance.
In December 1986, the then Radiation Safety Officer of the licensee initiated a site characterization in an effort to determine the presence, on the licen-i see's property, of burials of radioactive material.
Initial radiation surveys were performed and exploratory excavations were made in areas where burials were believed to have occurred.
One of the excavations resulted in a positive indication of radiation.
Subsequent soil and water samples from the location j
did not reveal any abnormal levels of radioactivity, leading to the conclusion that a contained radioactive source may be buried at this spot.
Subsequently, other information has been obtained which supports this conclusion.
In response to this finding, a Confirmatory Action Letter, dated March 24, 1987, was issued which documented the licensee's commitments to:
- 1) comprehensively survey the portion of the property suspected to contain buried radioactive mate-rial; 2) develop a plan to non-invasively detect buried matter, and 3) inform the NRC Region I Office prior to performing any invasive action to explore or uncover buried material.
These actions have been completed by the licensee, and several areas have been identified that require further evaluation.
An excava-tion of one of these areas on June 4, 1987, revealed an object that read 200 millirem per hour at contact.
29
l To supplement this effort, Region I contracted with Oak Ridge Associated Universities (0RAU) to perform an independent radiological survey of the unrestricted areas of RTI's property (that is, the areas not covered by the licensee's survey described above) in Rockaway, New Jersey.
While several items containing low-level radioactivity were found on the property, nothing of health or safety significance was detected.
On May 8, 1987, representatives from NRC Region I met with representatives from the New Jersey Department of Environmental Protection (NJDEP) to discuss items of mutual interest relative to RTI.
The NJDEP informed Region I representatives of its intent to perform, beginning about June 8, 1987, a major site characteri-zation effort, i.e., a Remedial Investigation / Feasibility Study (RIFS), to identify the presence and source of hazardous chemicals known to be contaminat-ing the ground water in the area of RTI.
A public meeting to describe this effort was held by NJDEP on May 14, 1987, and was attended by Region I represen-tatives.
,Public interest appeared to focus primarily on the nature and extent of the hazardous chemical waste and its impact of the local environment.
No significant interest has yet been expressed relative to burial of radioactive material.
A License Renewal Application was submitted by RTI on February 20, 1987.
The present license expired on February 28, 1987, but is currently being maintained effective based on this timely renewal application.
The Renewal Application is under review.
At the present time, RTI is operating normally.
Future reports will be made as appropriate.
1 1
30
APPENDIX C OTHER EVENTS OF INTEREST The following items are described below because they may possibly be perceived by the public to be of public health significance.
The items did not involve a major reduction in the level of protection provided for public health or safety; therefore, they are not reportable as abnormal occurrences.
Occasionally, this Appendix will include events involving exposures to very small areas of the skin (one square centimeter or less) which technically exceed the exposures shewn in Appendix A (see Example 1 of "For All Licensees") of this j
report.
The radiobiological literature indicates that an overexposure to a
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small area of skin (less than one square centimeter) would have much less health significance than a similar dose to larger areas of the body; consequently, such exposures would generally not be considered a major reduction in public health or safety (the general abnormal occurrence criterion) and therefore not reportable as abnormal occurrences.
However, all such events, together with the circumstances associated with the events, are reviewed individually to determine their relative significance, and if warranted, will be reported as f
abnormal occurrences.
1.
Airborne Radioactivity Leak into Zion Unit 1 Control Room On September 11, 1986, a vent path was inadvertently established from the waste i
gas system to the Zion Unit I control room, resulting in an unnecessary hazard j
to control room personnel.
Zion Unit 1 is a Westinghouse-designed pressurized water reactor operated by Commonwealth Edison Company (the licensee) and located in Lake County, Illinois.
The incident began when workmen lowered the level in the spent resin storage tank.
However, the level indicator on the tank was faulty; the level indicator showed the tank to be partially full when it actually was empty.
With all resins removed from the tank, contaminated waste gas from the tank entered the tank's drain system and then passed into the Auxiliary Building drain system through an interconnection.
The licensee later estimated that about 4,500 q
cubic feet of waste gas, including 8.2 curies of noble gases, were vented from the spent resin storage tank into the drain system.
From the Auxiliary Building drain system, some of the gas entered the Heating, Ventilating, and Air Conditioning Equipment Room, which is located in the Auxiliary Building.
This room contains the Control Room Ventilation System (CRVS) components, including the system's relief dampers.
Due to relief damper installation deficiencies in the CRVS (a condition which apparently had existed since 1971 when the relief dampers were installed), low concentrations of airborne radioactivity entered the control room.
Investigation later determined that the relief dampers in the two redundant return air fan trains of the CRVS were unfiltered inleakage pathways.
At the time of this incident, the Emergency Makeup Air Filtration System for the control room was in operation, but the inleakage through the relief dampers remained unfiltered because its entry point was downstream of the charcoal filters.
31
General Design Criterion 19 (GDC-19) of Appendix A, Title-10, Code of Federal i
Regulations, Part 50, requires that the control room be provided with adequate radiation protection to permit access and occupancy by control room personnel under accident conditions.
Personnel may receive no more than 5 rem whole body
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exposure for the duration of the accident, and no more than 30 rem to the i
thyroid.
Since the CRVS was operating in the accident mode at the time, the
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incursion of the noble gases into the control room raised the question of the adequacy of this system to meet its design requirements.
The actual radiological consequences of the event were very small.
Had a postulated design basis accident occurred at the time of the event, it is esti-mated (based on inleakage flows through the relief dampers as they were at the time of the event) that control room personnel could have received thyroid doses (from radioactive iodine) of about 380 rem from Train B or about 270 rem from Train A.
Either amount would exceed the 30 rem GDC-19 thyroid dose guideline.
j The cause of the event was due to the failure by the licensee to construct the CRVS in accordance with the approved design.
The design of the system called for one relief damper to be located in common discharge ductwork to the ventila-tion return fans.
However, the installation was such that each return fan has its own relief damper in its own separate discharge ductwork.
As a result, when a return fan in one train was operating, a leakage pathway existed into the CRVS through the common suction ductwork from the other train's relief damper.
The licensee took the following short-term steps to prevent a recurrence of the incident:
(1) closed the relief dampers and blanked them off with sheet metal to prevent further leakage; and (2) reviewed the system to identify other system /
installation discrepancies.
(No other ventilation system discrepancies were found that would affect the safety system function.) The long term corrective action includes consideration of several actions to enhance'the CRVS's perfor-mance, including the addition of bubble-tight dampers.
Other actions include:
I investigating the feasibility of permanent modifications to separate the CRVS from the plant's Technical Support Center Ventilation System (waste gas also entered this unit); revision of plant drawings to reflect as-built conditions in the CRVS; and a commitment to the NRC that a test will be conducted which l
demonstrates GDC-19 requirements are met after modifications are completed.
j The NRC has verified that the dampers have been closed and that sheet metal was used properly in the blanking-off process.
The NRC staff had previously informed the licensee in August 1985 that the use of silicone sealant and other temporary patching material on the CRVS are unacceptable, so the present blank-off of the relief valves may not be the final configuration.
The NRC has also met with the licensee to discuss implementation of corrective actions and continues to monitor the licensee's course of action.
2.
Falsification of Security Force Contractor Training and Qualification Records l
On September 25, 1986, a Federal Grand Jury indicted YOH Security Inc. (YOH),
along with some of its employees or its contractor employees, with charges of 32
conspiracy, false statements, and coverups, based on evidence discovered in 1984.
At that time, Y0H was a security. force contractor at the Limerick Generating Station.
Limerick is a General Electric-designed boiling water reactor, operated by Philadelphia Electric _ Company (PECO),_'and located in Montgomery County, Pennsylvania.
The circumstances associated with the event are.as'follows:
On August 10, 1984, a representative of PEC0-(the licensee) notified the NRC.
Resident Inspector at Limerick that, during -an audit of the overtime records 1 of the security force contractor, the auditor found _possible indications.that some guard force. training and qualification records may have been falsified.
At the time, an operating license for the station was pending.
NRC regulations (10 CFR S 73.55) require the applicant for a nuclear power-
'l station operating license ~to establish'a security organization to protect the-l station against radiological ~ sabotage and to train.and qualify members of the 1
security organization;in accordance with the NRC's " General Criteria for Security Personnel (10 CFR Part 73, Appendix.8)," prior to requesting an operating' license for the station.
Those regulations also require the licensee.(or its contractor)-
to maintain, for NRC inspection, records of the training and qualification of members of the security organization.
As a result of the notification to the N'RC Resident Inspector,.and a subsequent allegation by a former YOH employee, which was received in NRC Region I during '
3 September, 1984 and which provided further credibility to the falsification issue, the Regional Administrator of NRC Region I requested the NRC'.s Office.of Investigations (01) to conduct an investigation.
The' investigation was completed in February 1985 and established that there had been. widespread falsification" of security force training and qualification records at the direction of high level, on-site, Y0H security management.- There was no' evidence found that
)
implicated any employee of the licensee in the falsifications.
Prior to issuance of the operating license,.the applicant conducted remedial training for members of the guard force' and was-subsequently able to demonstrate to the NRC that the guard force had been adequately trained.
The. Limerick low power operating license was issued on October 26, 1984.
The OI investigation report was subsequently' turned over to the U.S. Attorney:
)
for the Eastern District of Pennsylvania,'and on September 25, 1986,'a Federal j
Grand Jury returned an indictment charging Y0H and several of.its former employees or its contractor employees with conspiracy, false statements and cover-ups in connection with training'and qualification records for the ' security.
force..0n March 20, 1987, YOH pled guilty.to 10 counts of violating l18 U.S.C.
1001, "The False Statement Statute," and paid a.$100,000' fine.
Two former Y0H employees, and a training contractor (who providedLweapons train-ing to Y0H under contract), had.been indicted along'with Y0H in September ~1986 but were tried separately.
One of the former.Y0H employees (who had been the security force Captain at the time of the falsification), pled guilty.to the charges and was a' key governmental witness in the trials.1The other former Y0H employee had been the Y0H Site Manager at the time of the falsif.ication.
During April 1987, the two former Y0H employees were convicted, while the train-
~
ing contractor was-found innocent of,all charges.
On July 15, 1987, the former 33
s
/
YOH Site Manager (having been found guilty of various criminal charges leading to obstruction of the NRC's lawful function in determining whether PECO, as an applicant for a license to operate a nuclear station, had a security organiza-tion that was properly trained and qualified) was sentenced to six months in prison and fined $30,000.
The other employee, who had cooperated with the Department of Justice, was placed on probation for five years.
The U.S. District Judge, in handing down the sentences, stated that the falsi-fication of training records had tainted the integrity of the nuclear industry.
The Assistant U.S. Attorney who prosecuted the government's case said that any-thing less than incarceration would have sent the wrong message to the nuclear industry.
The attorney for the former YOH Site Manager indicated that he would appeal the sentence on the grounds that it was a nonviolent, victimless crime.
3.
Overexposure of a Maintenance Worker's Hand at San Onofre Unit 3 During October 1986, while performing maintenance activities at San Onofre Unit 3, a licensee mechanic received an exposure to a small area of his right hand, estimated from a badge reading to be on the order of 512 rem.
The expo-sure was not reported until December 12, 1986.
San Onofre Unit 3 is a Combus-tion Engineering-designed pressurized water reactor operated by Southern California Edison Company (the licensee) and ' located in San Diego County, California.
On December 12, 1986, the licensee reported that an overexposure of a worker's right hand may have occurred during the month of October,1986.
The licensee did not discover the possibility of an overexposure occurring until December 11, 1986, because an error in their computer software had truncated the number reported to them electronically by their vendor.
The report was followed by Licensee Event Report (LER)86-015 (Ref. C-1) which detailed current information about the event but indicated the investigation was continuing.
The licensee issued Revision 1 of LER 86-015 (Ref. C-2) on February 22, 1987 reporting their conclusion that the overexposure did not occur.
The licensee issued Revision 2 of LER 86-015 (Ref. C-3) on May 7, 1987, stating that it had not been possible to determine whether or not an exposure occurred and providing their estimate of the " dose equivalent" to be 5.6 rem in this instance.
NRC inspections during the periods December 15, 1986; January 12-16, 1987; March 16-20, 1987; and May 8-14, 1987 (Refs. C-4 and C-5) found that no valid basis existed for discrediting or adjusting downward the reported dose of 511.99 rem.
Highly radioactive irradiated fuel fragments capable of delivering the dose were known to exist at the site and could have been deposited in the systems on which the mechanic worked.
The radiation and contamination surveys performed during the mechanic's work were routine, not documented, and performed by technicians untrained in methods needed to detect fuel fragments.
The phy-sical examination of the worker did not occur until two months after the poten-tial event.
No physiological effects to the hand were observed or are expected.
A laboratory analysis of a blood sample gave inconclusive results, but the re-sults could be considered consistent with a large dose to the hand.
The physically small irradiated fuel fragments (commonly referred to as " hot particles") that have been observed at San Onofre Nuclear Generating Station and 34
at other utilities can be intensely radioactive particles, 1E-3 to 1E+3 micro-curies, yet are very difficult to detect.. The contact dose rate of a 1 micro-curie particle can range from 3 to 9 rem /hr to one square centimeter-of. skin, depending on the age of the particle, yet it will be almost undetectable with commonly used hand held radiation survey instruments in moderate background radiation areas unless the instrument is within a.few centimeters of the particle.
c The particles are primarily beta emitters, beta maximum 3.5 MeV, with only an insignificant gamma component.
They appear to present an acute exposure hazard to small areas of the skin at high doses; i.e., 200-600 rem, erythema (reddening);
800-1100 rem, dry desquamation'(scaling); 1300-2000 rem, moist desquamation (blisters); 2000-2500 rem, ulceration.
As the skin is relatively' insensitive to radiogenic cancer initiation where very small areas are exposed, the stochastic consequences of particle exposure appear to be minimal.
The ultimate cause of the exposure appeared to be a failure of the. licensee to take action to control 'the spread of irradiated fuel fragments within primary plant and radioactive waste systems and to protect workers from the consequences of exposure to the particles after their discovery in late 1985 during fuel reconstitution.
Licensee management appeared to have adequate warning that a hazard could exist but failed to fully implement action to ameliorate its con-sequences outside their fuel handling building until December 1986.
As corrective actions, the licensee began a station-wide program to control irradiated fuel fragments in December 1986..This included general employee training on the nature of the particles and their hazards, specific training of health physics technicians in the characteristics of the particles and methods needed to detect and control them, institution of.a task force to recommend and implement action to minimize production and movement of' particles,'and procure-l 1
ment and use of highly sensitive whole body beta contamination detectors.- The 1,icensee also implemented, in January 1987, specific radiation protection p'ro-cedures to establish a three-zone control approach to protect workers from the particle hazards.
A special inspection of the event was conducted at San Onofre on the dates no'ted' above.
Additionally, an NRC Region V branch chief and a. consulting physicist visited the dosimetry vendor to review the processing of the TLD badge in ques-tion. The Region also obtained further assistance from a consulting physician and a contract laboratory.
The inspection results were forwarded to the licensee in a letter dated April 13, 1987.
A Notice of Violation and Proposed Imposition of Civil Penalty totaling $100,000 was transmitted to the licensee on June 25, 1987 (Ref. C-6).
Subsequently, the licensee paid the civil penalty.
4.
Overexposure of an Electrician's Hand at V. C. Summer
. South Carolina Electric and Gas Company, the licensee for the V. C. Summer Nuclear Station, reported to NRC Region 11 that on November 7,'1986,.an elec-trican received a calculated dose of 420 rem to one square centimeter of his-right hand skin at a depth of 7mg/cm. -Summer is a Westinghouse-designed 2
pressurized water reactor (PWR) located in Fairfield County, South Carolina.
35
The electrician was working on a control panel of the overhead crane in the fuel handling building.
This building was a radiologically clean area where no protective clothing was required.
When the individual exited the facility's radiation controlled area, after performing work on the crane, the personnel contamination monitoring instrument through which he passed alarmed.
Health Physics personnel, using a portable instrument with a hand-held probe, deter-mined that the individual was contaminated on the back of his right hand.
A survey was performed using a beta gamma survey meter which indicated that the exposure rate from the contamination was 1.0 millirem per hour from gamma radia-tion, and 2,000 millirem per hour from beta radiation.
The worker was decontaminated by wiping the contaminated area with warm water I
and soap.
Health Physics personnel did not retain what was believed to be a single radioactive particle.
The dose to the skin of the hand, using the guidance of NRC Inspection and En-forcement Notice No. 86-23, " Excessive Skin Exposures Due to Contamination with Fot Particles" (Ref. C-7), was calculated to be 420 rem.
However, bec' use the a
calculated dose is a conservative value and the safety implications of the dose are considered to be significantly reduced because of the extremely limited area j
of exposure, the consequences of the exposure are considered to be small.
In l
addition, the individual's hand was examined by a physician and no effects of i
the exposure were observed.
It should be noted that the licensee does not j
agree with the NRC approved calculational method.
The licensee believes l
that current understanding of the stochastic risks associated with the skin dose results in a correct dose equivalent of 0.43 rem.
l While the overexposure most likely was due to a single radioactive particle, l
the licensee was unable to determine where the particle originated.
Extensive contamination surveys performed by the licensee in the fuel handling building l
did not find any additional radioactive contamination.
No inadequacies'in the licensee's contamination control program were identified.
Other actions taken included development of a procedure for identification and evaluation of such exposures, and retraining of licensee staff on skin contamination evaluation.
The NRC performed an inspection on November 20-21, and December 16, 1986, to review the circumstances associated with the event (Ref. C-8).
One violation of regulatory requirements was identified, in addition to the violation for an i
apparent exposure in excess of NRC limits.
Subsequent action included an enforcement conference with licensee management and the issuance of a Notice of Violation on March 10, 1987 (Ref. C-9).
l 5.
Radioactive Contamination of Site On March 11, 1987, the U.S. Environmental Protection Agency (EPA) began stabi-lization of a site (formerly used by a NRC licensee) which had been declared a hazard to the health and safety of the public.
The circumstances associated with the event are as follows.
The Pesses Company of Solon, Ohio, was authorized by NRC license to possess and reprocess scrap alloys containing thorium at a site near Pulaski (Lawrence County), Pennsylvania.
An inspection at Pulaski on September'21, 1984, found 36
the site apparently abandoned and the licensee in bankruptcy.
A large number of barrels and boxes containing unrecovered thorium alloys was still present at the site.
Thorium contamination was found in the soil and in the building on the property.
Region I concluded that the radioactive materials on the site did not present an immediate threat to the health and safety of the public but were present in amounts and concentrations in excess of NRC criteria for release for unrestricted use.
Remedial action was, therefore, required.
On January 22, 1986, the NRC issued an Immediately Effective Order requiring the trustee in bankruptcy to clean up the site.
The trustee refused to. comply.
Subsequently, the NRC Office of General Counsel, in cooperation with the Depart-ment of Justice, filed a motion in bankruptcy court to have available funds preferentially applied to site cleanup.
On November 18, 1986, the motion was denied.
NRC survey information was forwarded to the EPA and the Commonwealth of Pennsylvania.
Based on the results of the hazardous materials analysis per-formed by the NRC, EPA conducted more extensive evaluations of the site during June, July, and August of 1986.
During September of 1986, EPA informally com-municated its preliminary findings to the Commonwealth of Pennsylvania and the Centers for Disease Control (CDC).
After evaluation of the information provided, both Pennsylvania and the CDC certified to the EPA that the site is a hazard to the health and safety of the public as a result of the chemical toxicity of the materials on site.
This finding allowed EPA to take remedial action under federal statutes, such as the Comprehensive Environmental Response, Compensation and Liability Act of 1980 (CERCLA) and the Superfund Amendments and Reautho-rization Act of 1986 (SARA).
On March 11, 1967, EPA began emergency site stabilization.
An EPA contractor consolidated all soil and items contaminated with radioactive or hazardous material in a central location on the site in a stable configuration.
Work was completed on April 17, 1987, and a subcontractor completed perimeter fencing on I
April 20.
The site is designed to remain stable for at least one year.
During this year, EPA plans to negotiate with the " Potential Responsible Parties" in an attempt to achieve final decontamination of the site.
The NRC Region I office will continue to work with the EPA to assure that any steps taken with regard to this site conform to NRC requirements.
6.
Corrosion Due to Boric Acid Deposits on the Turkey Point Unit 4 Reactor Vessel Head, Associated Components, and Surrounding Areas On March 19, 1987, the NRC sent an Augmented Inspection Team (AIT) to Turkey Point Unit 4 to review the circumstances associated with an instrument seal leak identified by Florida Power and Light Company (the licensee), with possible
{
corrosion caused.by deposits of crystalline boric acid and on the reactor vessel i
head, associated components and surrounding areas.
Turkey Point Unit 4 is a Westinghouse-designed pressurized water reactor located in Dade County, Florida.
The AIT conducted inspections through March 24, 1987, to ascertain the causes l
and effect of the instrument seal leak.
The AIT did not conclude its inspection at that time due to the ongoing activities by the licensee to develop a root cause analysis, engineering evaluations, and any necessary repairs, which 37
required subsequent inspection activities.
Onsite AIT activities continued until April ~23,1987.
The results of the AIT review are contained in Inspection Report No. 50-251/87-16 which was issued on May 15, 1987 (Ref. C-10).
Summarized below is a brief description of the (a) failed component, (b) circumstances associated with the event, and (c) actions taken by the licensee and NRC.
(a) Description of Failed Component The reactor incore thermocouple system utilizes 52 thermocouple to measure fuel assembly coolant outlet temperature at preselected core locations.
The thermocouple conduits enter the reactor vessel closure head through port columns which protrude through four vessel head penetrations.
The thermocouple conduits are welded to a seal plug / port column seal adapter assembly to provide a path for the thermocouple leads through the reactor closure head.
This path is through a conoseal assembly which is a mechanical connection with two gasketed seals to prevent reactor coolant leakage.
The lower gasket seal is established by applying a compressive force on the assembly to seat and compress the gasket.
The compressive force is applied using a special fixture and a hydraulic ram port-a power.
While the assembly is compressed (with a load of 5720 to 6310 psi) a three' piece clamp is bolted around the beveled flanges of the assembly to maintain the compressive load.
The bolts are torqued to 125 ft-lb.
l After the loading device has been removed, the upper seal is compressed by installing a jack screw plate and split ring at the top of the assembly.
The jacking screws on the upper seal are torqued to 100 in-lb.
The leak occurred at the lower seal of the conoseal assembly.
This per-mitted reactor coolant, which is borated with boric acid, to escape; boric acid can rapidly corrode ferritic (carbon) steel components.
l (b) Circumstances Associated with the Event l
In early August 1986, Unit 4 began a restart following a seven-month outage.
l The reactor was taken to Mode 3 (hot standby) on August 10 and, following l
the completion of heatup, a visual leak rate inspection was performed by l
the licensee on August 12.
At this time, there was no indication of leak-l age from any of the conoseals.
The conoseal leak was apparently first noticed by a maintenance foreman who was performing a containment closeout inspection early on the morning of August 30.
The foreman stated that he specifically looked at the 'four conoseals from the 58 foot (refueling floor) elevation using a flashlight and he noticed a " fine mist and spitting" from the affected conoseal.
The l
information about the leak was passed on to the maintenance superintendent l
who, along with a Quality Control inspector, went into containment to inspect the conoseal.
Site engineering personnel were requested to per-form an analysis of the leak.
A Safety Evaluation (SE) was issued and the licensee made a technical decision to operate with the leak.
On August 30, September 2, and 3, the Westinghouse site representative informed his management of the leaking conoseal and the licensee's decision to operate.
38
On October 24, 1986, when the plant was shut down for unscheduled condenser maintenance, an inspection of the conoseal leak was conducted by the en-gineer who wrote the SE and the Mechanical Maintenance Supervisor.
They did not observe any abnormal indications aside from the leak; however, a maintenance worker who had been sent into containment to clean the conoseal in preparation for the inspection noted a significant buildup of boric acid on the surfaces of the reflective insulation and the cavity floor.
This worker estimated the layer of boric acid was less than 1/2" at the maximum point and extended over a 6-to 8-foot wide area.
The worker cleaned up this residue and he stated that he saw no areas of corrosive damage.
As a result of the inspection by the engineers and Mechanical Maintenance Supervisor, it was concluded that the original SE was still valid and that an inspection should be carried out by February 28, 1987.
As the February 1987 inspection date approached, the Plant Manager requested a reevaluation of the need for the inspection since it would require shut-ting down Unit 4.
Site engineering wrote a memo dated February 26, 1987, which concluded that since the October 24, 1986, inspection of the conoseal leak was satisfactory, the six-month inspection requirement may be revised to six months from that date rather than from August 30, 1986.
On March 11, 1987, Unit 4 was manually shutdown as required by Technical Specifications due to a leak in the containment personnel hatch inner door.
j
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While Unit 4 was being maintained in Mode 3, on March 13, 1987 site engi-
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neering was informed by Westinghouse that potential corrosion rates from the known conoseal leak on the Unit 4 reactor head penetration, as evaluated in the previously mentioned SE, were inaccurate and the accurate corrosion rates may be double those previously assumed; Westinghouse also recommended an immediate inspection of the conoseal clamp.
Unit 4 was immediately taken to Mode 5 (cold shutdown) to assess the leak and the extent of the boric acid contamination and subsequent surrounding corrosion areas.
Consequently, licensee personnel entered Unit 4 containment and observed that the conoseal, instrument tube / head penetration, reactor head, head flange, studs and nuts above the head flange, control rod drive mechanism (CRDM) forest, heat vent shroud, CROM cooler ventilation duct, head lifting lug and the vessel head insulation were affected by the boric acid leak.
There was a buildup of about 500 pounds of boric acid crystals on the conoseal/ reactor head area.
From a metallurgical point of view, the licensee visually inspected the reactor vessel closure pressure boundary materials which consist of low t
alloy ferritic steel fasteners, manganese-molybdenum-nickel ferritic steel head and shell flanges, and an austenitic stainless steel "0" ring gasket.
It was observed that the leak from the conoseal had affected the fasteners and the head and shell flanges.
Twenty-eight of the 58 reactor vessel head studs were affected by the boric acid leak.
Eight of the studs were encrusted with boric acid deposits; of these eight, three were signifi-
]
cantly corroded as were their associated nuts.
In addition, a fourth nut
)
had some loss of castellation.
The immediate cause of the boric acid leak was the failure of the conoseal.
The failure was apparently initiated by an improperly assembled lower conoseal ring.
The clamping force of the conoseal flange was not adequate 39
to prevent leakage past the seal.. Once the seal started leaking, the borated water / steam began to attack the clamp thereby decreasing the clamping force even further.
A significant contributing cause to the severity of the event was failure to properly evaluate the leak in terms of the boric acid corrosion of ferritic steel components.
There was also a deficiency in the licensee's operational feedback prograin in that various reports on boric acid attack issued by the NRC and the Institute of Nuclear Power Operations'(INP0) were neither properly evaluated nor utilized.
The event could have been avoided, or the severity considerably mitigated, j
if the licensee had taken timely action to characterize and repair the leak after it was first detected during late August 1986.
(c) Corrective Actions Commencing on March 13, 1987, the licensee performed thorough and extensive
'I inspections and evaluations to identify the extent of the components /
equipment which were subject to boric acid corrosion.
These included inspections of the items in the area of the reactor vessel head as well as in the containment that might have been affected by the conoseal leakage.
The licensee elected to remove and replace, one at a time, the three seri-ously corroded studs with Unit 3 studs prior to detensioning and removing the vessel head.
Ultimately, seven sets of studs, nuts, and washers were replaced with newly procured sets.
The licensee also initiated 24.non-conformance reports (NCRs) for the recovery effort.
The reactor vessel head in the area of studs 22-28 was ultrasonically inspected as well as penetration No. 53 counterbore.
All acceptance criteria were satisfied during the inspection.
The licensee also issued a report on the conoseal leakage and made commitments containing a number of improvements in leak detection procedures, hardware changes, and preparation and review of Safety Evaluations.
As part of the recovery program, the licensee also developed new procedures (or revised existing procedures) to ensure that leaks in borated water l
systems are detected and evaluated as soon as possible.
These are applic-I able to both Turkey Point Units 3 and 4.
The NRC AIT performed independent reviews in the following areas:
(1) design of the conoseal connections:
(2) procedures for assembly of the conoseal connections; (3) reactor vessel materials and potential for damage by exposure to concentrated boric acid; (4) nondestructive examina-tion procedures and programs; (5) reactor system leak rate calculations; (6) containment radiation monitoring systems; (7) the licensee's engineer-ing analysis of this event; (8) response to previous industry experience with boric acid corrosion; and (9) the licensee's recovery program.
Three violations were identified by the AIT:
(1) failure tu properly eval-uate the effects of the leak in terms of the boric acid corrosion of ferritic steel components; (2) failure to properly adhere to the installation and drawing requirements of the conoseal; and (3) the leak rate procedure was 40
I l
inaccurate in that correction factors were incorrect.
The NRC letter for-j warding the AIT report to the licensee (Ref. C-10) stated, however, that a formal Notice of Violation was not being issued at the time because the violations were being considered for escalated enforcement action.
On April 20, 1987, the NRC issued NRC Information Notice (IN) No.86-108, Supplement 1 (" Degradation of Reactor Coolant System Pressure Boundary Resulting from Boric Acid Corrosion") to all pressurized water reactor (PWR) facilities holding an operating license or a construction permit (Ref. C-11).
The Supplement alerted recipients that the Turkey Point Unit 4 event was another severe instance of boric acid induced corrosion of ferritic steel components on the pressure boundary of a PWR.
The notice supplemented IN No.86-108, issued December 29, 1986 (Ref. C-12) which described boric acid corrosion at Arkansas Nuclear One, Unit 1 in October 1986 and at Calvert Cliffs Unit 2 in 1981.
IN No.86-108 also mentioned that problems of boric acid corrosion wastage was the subject of NRC Inspection and Enforcement Bulletin No. 82-02 (" Degradation of Threaded Fasteners in the Reactor Coolant Pressure Boundary of PWR Plants")
which was issued June 2, 1982 (Ref. C-13).
The licensee completed its recovery program to the satisfaction of NRC and commenced startup of Unit 4 in early July 1987.
However, an unrelated operational problem developed which precluded startup until it was resolved.
Subsequently, Unit 4 achieved full power operation on July 12, 1987.
On July 21, 1987, the NRC sent to the licensee a Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $100,000 (Ref. C-14).
Of this amount, $50,000 was for the first violation previously discussed; the other $50,000 was for a separate issue involving a violation of tech-nical specifications which occurred on April 7,1987 during core altera-tions activities.
These two violations were classified as a Severity Level III problem (on a scale in which Severity Levelt I and V are con-sidered the most severe and least severe, respectively) and represented a 100% escalation in the base value of a Severity Level III problem.
The other two violations previously discussed above were classified as Sever-ity Level IV and were not assessed a civil penalty.
41
REFERENCES FOR APPENDICESt B-1 U.S. Nuclear Regulatory Commission, " Programmatic Environmental Impact Statement Related to Decontamination and Disposal of Radioactive Wastes Resulting from March 28, 1979 Accident, Three Mile Island Nuclear Station, Unit 2, Docket No. 50-320," Draft NUREG-0683, Supplement No. 2 (dealing with disposal of-accident generated water) issued for public comment during December 1986.**
B-2 Letter from James M. Taylor, Director, NRC Office of Inspection and.
Enforcement, to Joe Williams, Jr., Senior Vice President-Nuclear, Toledo Edison Company, forwarding a Notice-of Violation and Proposed' Imposition of Civil Penalties, Docket No. 50-346, December 13, 1985.*
B-3 Letter from James M. Taylor, Director, NRC Office of Inspection and Enforcement, to Paul M. Smart, Chairman'and Chief Executive Officer, Toledo-Edison Company, forwarding an Order-Imposing Civil Monetary Penalties, Docket No. 50-346, February 12,'1987.*
B-4 10 CFR S 50.54(f) letter from James G. Keppler, Regional Administrator, NRC Region III, to Cordell Reed, Vice President, Commonwealth Edison i
Company, Doc ket Nos. 50-373 and 50-374, November 22, 1985.*
B-5 Letter from A. Bert Davis, Regional Administrator, NRC Region.III, to Cordell Re'ad, Vice President, Commonwealth Edison Company,Eforwarding Systematic Assessment of Licensee Performance Report Nos. 50-373/86-06 and 50-374/86-07, Docket Nos. 50-373 and 50-374, March 4, 1987.*
B-6 Letter from James G. Keppler, Regional Administrator, NRC Region.III, to l
James J. O'Connor, President, Commonwealth Edison Company, forwarding a Notice of Violation and Proposed Imposition of Civil Penalty, also forward -
ing Inspection Reports No. 50-373/85-33 and No. 50-374/85-34, Docket 1
Nos. 50-373 and 50-374, March 19, 1986.*
i B-7 U.S. Nuclear Regulatory Commission, Inspection and Enforcement Compliance Bulletin No. 86-01, " Minimum Flow Logic Problems That Could Disable RHR Pumps," May 23, 1986.*
B-8 U.S. Nuclear Regulatory Commission, Inspection and Enforcement Compliance Bulletin No. 86-03, " Potential Failure of Multiple ECCS Pumps Due to' Single Failure of Air-0perated Valve in Minimum Flow Recirculation Line,"
October 8, 1986.*-
i i
- Available in NRC Public Document Room, 1717 H Street, NW., Washington, DC l
20555, for public inspection and/or copying.
{
- A free single copy of draft NUREG-0683, Supplement No. 2, may be requested
{
by those considering public comment by writing to the U.S. Nuclear'Regula-I tory Commission, ATTN:
Distribution Section,. Room P-130A, Washington, DC-
'l 20555.
A copy is also available for inspection and/or copying in the NRC Public Document Room, 1717 H Street, NW., Washington, DC.
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s B-9 U.S. - Nuclear Regulatory Commission, Inspection u,rl ',ifo,rcement Bulletin No. 80-18, " Maintenance'of Adequate Minimum Flow hirough Centrifugal Charg-
{
ing Pumpi Following Secondary Side High Energy L'ne Rupture," July 24, 1980.*
B-10 Case Study Report, " Air Systems Problems at-U.S. Light Water Reactors,"
J AE00/C701 prepared by Dr. Harold Ornstein, NSC Office for Analysis and 1
Evalua+. ion of Operational Data, March, 1987.*-
j V
B-11 U.S. Nuclear Regulatory Commission,,NRC Information Notice No.'87-28, " Air Systems Problems at U.S. Light Water Reactors," June 22, 1987.*
a B-12 Letter P om J. Nelson Grace, Regional Administrator, NRC Region II,-to H. B. Tucker, Vice President, Nuclea6 Production Department, Duke Power
)
Company, forwarding a Notice of Violation and Proposed Imposition of Civil Penalty, Docket Nos. 50-413 and 50-414, November 12, 1986.*
B-13 Letter from H. J1. Tucker, Vice President, Nuclear Production' Department, Duke Power Company, to James M. Taylor, Director, NRC Office of Inspection and Enforcement, Docket Nos. 50-413 and 50-A14, December 12, 1986.*
)
y B-14 Letter from James M. Taylor, NRC Deputy Eh cutive Director dor Regional Operations, to H. B. Tucker, Vice President, Nuclear Production Department, Duke Power Company, forwarding an Order Imposing Civil Monetary Penalty with Appendix, Do:ket No. 50-414, April 19, 1987.*
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>,1 i
C-1 LetterfromH.E. Morgan,Sarn0nofreStationManager, South (rnCalifornia l
Edison Company, to U.S. Nuclear Regulatory Commissior., Document Control l
Desk, forwarding CER 86-015, Docket No. 50-362, January 12, 1987.*
i C-2 Letter from H. B. Ray, Vice President ard Site Manager, Southern California i
Edison Company, to U.S. Nuclete Regulatory Commission, Document Control I
Desk, forwarding LER 86-015, Revision 1, Docket No. 50-362, February 22, 1987.*
C-3 Letter from H. B. Ray, Vice President and Site Manager, Southern California Edison Company, to U.S., Nuclear Regulatory Commission, Document Control Desk, forwarding LER 86-015, Revision 2, Docket No. 50-362, May,7, 1987.*
C-4 Letter from R. A. Scarano, Director, Division of Radiation Safety'and Safeguards, NRC Region V, to K. P. Baskin, Vice President, Southern California Edisen Company, forwarding Inspection Report NO. 50-362/86-37, l
Docket No. 50-362, April 13, 1987.*
C-5 Letter from R. A. Scarano, Director, Division of Radiation Safety and
{\\
l Safeguards, NRC Region V, to K. P. Baskin, Vice President, Southern
'3 California Edison Company, forwarding Inspection Report No. 50-362/87-13, V
l Docket No. 50-362, May 28, 1987.
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- Available in NRC Public Document Ro p, 1717 H Street, NW., Washington,,nc 20555, for public inspection ar,d/or bopying.
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C-6 LMter from J. B. Martin, Regional Administrator, NRC Region V, to K. e. BaMin, Vice President, Southern California Edison Company, forward-ing a Notip of Violation and Proposed Imposition of Civil Penalty, Docket No. 50-362, June 25, 1987.*
1 C-7 U.S. Nuclear Regulatory Commission, Inspection and_ Enforcement Information
.lotice No. 86-23, " Excessive Skin Exposures Due to Contamination with Hot s
\\
p Facticles," April 9, 1986.*
C-8 Letter, forwarding Inspection Report No. 50-395/86-22, from J. Nelson Grace, Regional Administrator, NRC Region II, to D. A. Nauman,'Vice President, Nuclear Operations, South Carolina Electric and Gas Company, Docket No. 50-395, March 12, 1987.*
s-I tetter, forwarding Notice of1 Violation, from J. Nelson Grace, Regional C-9 Administrator, NRC Region II, to D. A. Nauman, Vice Presioent, Nuclear Operations, South Carolina Electric and Gas Company, Docket No. 50-395,_
March 10, 1987.*
C-10 Letter from J. Nelson Grace, Regional Administrator, NRC Region II, to C. O. Woody, Group Vice President, Nuclear Energy Department, Florida l
Power and Light Company, forwarding "NRC Augmented Inspection Team Report I
Y No. 50-251/87-16," Docket No. 50-251, May 15, 1987.*
fC-11 U.S. Nuclear Regulatory Commission, NRC Inf$rmation Notice No.86-108, f Supplement 1, " Degradation of Reactor Coolant Syst p/.* Pressure Boundary Resulting from Boric Acid Corrosion," April 20,190 i
[
C-l'2 U.S. Nuclear Regulatory Commission, Inspection and Enforcement Information Notice flo.86-108, " Degradation of Reactor Coolant Syste;l Pressure Boundary Resulting from Boric Acid Corrosion," December 29, 1986.*
C-13 U.S. NuckarsRegulatory Co' mission, Inspection and Enforceme'nt Bulletin m
No. 82-UJ, " Degradation of Threaded Fasteners in the Reactar. Coolant Pressure" Boundary of PWR Plants," June 2,1982.*
t C-14 Letter from J. Nelson Grace, Regional Administrator, M C Region II, to C. O. Wood /, Group Vice President, Nuclear Energy Department, Florida Power and Light Udmpaay, forwarding " Notice of Violation and Proposed Imposition of Civil Penalty," Docket Nos. 50-250 and 50-251, Juiy 21, 1987.*
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- Available in NRC Public Document Room, 1717 H Street, NW., Washington, DC 20555, for public inspection and/or copying.
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BIBUOGRAPHIC DATA SHEET NUREG-0090 niiNsraverikN v e aevias, Vol. 10, No. 1, j
2 ina.~o suoi
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Report to ress on. Abnormal Occurrences January-Marc 987
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r aun.oais, October 1987
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1987 c > n a.oa
,~o o%.Na.noN,.... m W,.oo ess uw e., c,
e e w eet.v.s. K w.a ~o Nu ea Office fer Analysis an ~ valuation of Operational Data
,,,,,,c U.S. Nuclear Regulatory s mmission e
Washingtca, DC 20555~
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to sacNsoa.No cao.Nu.TsoN N.we.No u.iuN spo s ue.,se /,a coa.,
f yet of atPQHT Same as 7, above.
Quarterly O Vtaeno covt HLo uwunwo nateel January-March 1987 i
f u si reawwamre.
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Section 208 of the Energy Reorganizati
'Ac' of 1974 identifies an abnormal occurrence as an unscheduled incident or event whi e' Nuclear Regulatory Commission determines j
to be significant from the standpoint of blic health and safety and requires a quartedy report of such events to be m to Congress. This report covers the period i Jtnary 1 to' March 31, 1987..During t r ort period, there was one abnormal occur-c'ence at the nuclear power plants li sed operate.
The item involved the'NRC suspension of power operations of t Peach a ttom Facility due to inattentiveness of Lw control room staff.
There wer seven atn
,al' occurrences at the other NRC' licensees.
Four involved diagnoe ic medica 1 m1, administrations; the other three involved breakdowns in manageme controls at t.t e separate industrial radiography licensees.
There here two abn. mal occurrences r orted by the Agreement'Staten Both invo~lved breakd uns in. manage ent controls at indu rial radiography. licensees.
The report also contains inform ion updating some prev usly reported abnormal occurrences.
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14 DOCUME NT.N.L v$l$ - e ett vWoa' ; ws;.iiPtoHS 16 LAB Tv Suspension mf Po _r Operations; Inattentiveness of Control om Staf f; 7
Diagnostic Med' al Misadministration; Breakdown in Manageme or Pro-Unl imi ted cedural Contr s; Radiation Safety Program; Irradiator Facili 'es; Industrial P diography Licenses; Airborne Radioactivity in a Co trol l[9",*"*'*T
,,MR9%fo9dl Ne'1i3,1on of Records; Hot Particles; Overexposure to mall Areas of in; Radioactive Contamination; Boric Acid Corrosion ci Reactor <r~cl a s si fi ed{
Un
.,u Compone s.
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