ML20237E271
| ML20237E271 | |
| Person / Time | |
|---|---|
| Site: | Crystal River  |
| Issue date: | 12/18/1987 |
| From: | Grace J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| To: | Wilgus W FLORIDA POWER CORP. |
| References | |
| NUDOCS 8712280243 | |
| Download: ML20237E271 (21) | |
Text
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- y, DEC 1 R 1987 Docket No. 50-302 License No. DPR-72 Florida Power Corporation Mr. W. S. Wilgus Vice President Nuclear Operations ATTN: Manager, Nuclear _ Licensing P. O. Box 219 Crystal River, FL 32629 Gentlemen:
SUBJECT:
ENFORCEMENT CONFERENCE
SUMMARY
(NRC INSPECTION REPORT.NO. 50-302/87-35)
This letter refers to the Enforcement Conference held at our request on-December 11, 1987.
This meeting concerned activities authorized for your -
Crystal River facility. The issues discussed at this conference ~ related -to the.
significant potential for excessive personnel exposure as_ a result of the unauthorized removal of lead bricks serving as the. access barrier to the reactor area. A summary, a list of attendees, and a copy of your handout are enclosed.
It is our opinion that this meeting was beneficial and has provided a better 4
understanding of the inspection findings, the enforcement issues, and the status of your corrective actions.
We are continuing our. review of these issues to determine the appropriate enforcement action.
In accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this' letter and its enclosures will be placed in the NRC Public Document Room.
Should you have 'any questions concerning 'this matter, please contact us.
Sincerely, J. Nelson Grace Regional' Administrator
Enclosures:
1.
Enforcement Conference Summary 2.
List of Attendees 3.
Handout cc w/encls:
(See page 2) 8712280243 871218 PDR ADOCK 05000302 PDR r
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DEC 181987 r
Florida Power Corporation 2
cc w/encis:
P. F. McKee, Director, Nuclear Plant Operations E. C. Simpson, Director, Nuclear Site Support bec w/encis:
NRC Resident Inspector DRS Technical Assistant Document Control Desk State of Florida J. Lieberman, DOE G. R. Jenkins, EICS
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s ENCLOSURE 1 Enforcement Conference Summary Licensee:
Florida Power Corporation Facility:
Crystal River Docket No.-
50-302
Subject:
Significant Potential for Excessive Exposure as Result of Removal of Lead Bricks from the Reactor Cavity Access Licensee representatives described the sequence of events and their corrective actions for the apparent violations discussed in the Inspection Report Details.
In addition to the corrective actions described in the report, licensee representatives stated that three other areas in the plant had been identified which required enhanced controls to preclude unauthorized access.
They also discussed training and procedural changes that had been made or were in progress.
They stated that their corrective actions had been extensive and that recognition should be given for the programmatic improvements they have made over the past year.
NRC representatives discussed the seriousness of the event and emphasized the potential for excessive exposures and the need to take action as necessary to preclude such events.
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w ENCLOSURE 2 List of Attendees Florida Power Corporation P. McKee, Director, Nuclear Plant Operations S. Robinson, Chemistry and Radiation Protection Superintendent D. Wilder, Radiation Protection Manager E. Simpson, Director, Nuclear Operations Site Support W. Marshall, Nuclear Shift Supervisor R. Rehberg, Auxiliary Nuclear Operator R. Widell, Director, Nuclear Operations, Engineering and Projects K. Wilson, Manager, Nuclear Licensing Nuclear Regulatory Commission M. Ernst, Deputy Regional Administrator J. P. Stohr, Director, Division of Radiation Safety and Safeguards W. Hehl, Deputy Director, Division of Reactor Projects D. Collins, Chief. Emergency Preparedness and Radiological Protection Branch C. Hosey, Chief, Facilities Radiation Protection Section R. Weddington, Senior Radiation Specialist L. Trocine, Enforcement Specialist T. Stetka, Senior Resident Inspector B. Wilson, Chief, Projects Branch 2 G. Jenkins, Director, Enforcement and Investigations Coordinator Staff J. Wigginton, Chief, Facilities Radiation Protection Section, NRR l
ENCLOSURE 3 SEQUENCE OF EVENTS APPROXIMATE TIME - 10/8/87 - 2024 EVENT - NON-LICENSED OPERATORS (2)
SIGNED IN ON RWP R87-368 TO ENTER THE REACTOR BUILDING (RB)
AND MOVE THE AUXILIARY FUEL HANDLING BRIDGE FOR MECHANICAL MAINTENANCE.
APPROXIMATE TIME - 10/8/87 - 2130 EVENT - NON-LICENSED OPERATORS (2)
FINISHED MOVING THE AUXILIARY FUEL HANDLING BRIDGE AND CONTACTED THE CONTROL ROOM FOR FURTHER WORK ASSIGNMENTS IN THE RB.
APPROXIMATE TIME - 10/8/87 - 2135 EVENT - NON-LICENSED OPERATORS (2)
WERE TOLD TO WAIT INSIDE THE RB FOR A LICENSED OPERATOR IN PREPARATION TO RAISE THE FUEL TRANSFER CANAL LEVEL TO JUST ABOVE THE REACTOR VESSEL (RV)
SEAL RING.
SEQUEXCE OF EVENTS APPROXIMATE TIME - 10/8/87 - 2200 EVENT - ONE NON-LICENSED OPERATOR WAS ASSIGNED TO MONITOR THE LEVEL IN THE FUEL TRANSFER CANAL.
THE LICENSED OPERATOR WAS ASSIGNED TO MONITOR THE RV LEVEL USING A LEVEL GAUGE.
THE OTHER NON-LICENSED OPERATOR WAS TO CHECK FOR LEAKAGE AT THE BASEMENT OF CONTAINMENT.
APPROXIMATE TIME - 10/8/87 - 2300 i
EVENT - A NON-LICENSED OPERATOR ENTERED THE "D"
RING TO CHECK FOR LEAKAGE.
THIS NON-LICENSED OPERATOR REMOVED THE TOP
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TWO LAYERS OF LEAD BRICKS TO SECURE A q
BETTER VIEW OF THE AREA UNDER THE RV.
APPROXIMATE TIME - 10/8/87 - 2345 4
EVENT - THE NON-LICENSED OPERATOR WAS RELIEVED BY A SECOND NON-LICENSED OPERATOR.
TURNOVER INCLUDED A WARNING ABOUT HIGH DOSE RATES IN AREA 0F OPENING.
lf SEQUEXCE OF EVENTS 1
APPROXIMATE TIME - 10/8/87 - 2355 EVENT - HP ARRIVES AND SECURES THE AREA.
APPROXIMATE TIME - 10/8/87 - 2400 EVENT - THE iST NON-LICENSED OPERATOR REPORTED '
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TO THE CONTROL ROOM AND HP THAT HIS LOW RANGE DOSIMETER WAS OFF SCALE AND HIS HIGH RANGE DOSIMETER WAS INDICATING A DOSE OF 490 mR.
APPROXIMATE TIME - 10/9/87 - 0015 EVENT - MANAGEMENT WAS INFORMED.
R8 WORK WAS TERMINATED AND ALL PERSONNEL WERE REQUIRED TO EXIT THE RB.
(MANAGEMENT INCLUDED THE MANAGER ON CALL,
- RPM, AND THE CHEM / RAD SUPERINTENDENT.)
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s POSITIVE ACTIONS ~0Fs NiON-LICENSED OPERATOR o
POSITIONED DOSIMETRY HIGH ON HIS COVERALLS WHERE THEY WOULD REGISTER MAXIMUM EXPOSURE.
o POSITIONED DOSIMETRY NEXT TO HIS HEAD WHILE LOOKING INTO THEl0PENING(,
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POSITIONED HIMSELF IN A LOW DOSE AREA WHILE WAITING TO MINIMIZE HIS EXPOSURE.
o WARNED OTHER WORKERS IN THE AREA TO AVOID THE OPENING.
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INFORMED RELIEVING NON-LICENSED OPERATOR OF RADIATION' CONDITIONS.
o REPORTED HIS OFF SCALE LOW RANGE DOSIMETER TO HP.
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c POSITIVE ACTidNS OF HEALTH PHYSICS
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TOOK POSITIVE CONTROL OF THE AREA UPON DISCOVERY.
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HAD ALL PERSONNEL LEAVE THE RB.
o ACCOUNTED FOR ALL PERSONNEL IN THE RB AND MONITORED AND REVIEWED THEIR EXPOSURES.
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PERFORMED NECESSARY SURVEYS.
o REMOVED AND READ NON-LICENSED OPERATOR'S TLD.
o REPLACED LEAD BRICKS.
o WALKED DOWN THE RB TO ASSURE NO ONE WAS LEFT 1
INSIDE.
o PLACED HP TECH AT RB ENTRANCE TO RESTRICT i
ACCESS.
o TOOK WRITTEN STATEMENTS OF ALL INVOLVED.
O NOTIFIED MANAGEMENT.
ACTIONS OF MANAGEMENT
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IMMEDIATE ACTIONS o
MANAGEMENT REVIEW / RESPONSE TEAM WAS IMMEDIATELY ASSEMBLED.
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ALL RB WORK WAS TERMINATED UNTIL THE MANAGEMENT REVIEW WAS COMPLETED (8 HRS. ).
o THE LEAD BRICKS WERE POSTED, "HIGH RADIATION AREA INSIDE, DO NOT REMOVE LEAD BRICKS."
o A CHECK OF THE SHIELDED ACCESS OPENING WAS CONDUCTED EVERY 15 MINUTES UNTIL A LOCKED COVER PLATE COULD BE INSTALLED (1 WEEK).
o SIGNS WERE POSTED AT THE HP-RWP SIGN-IN i
AREA AND ENTRANCES TO THE AUXILIARY BUILDING j
AND RB READING "D0 NOT PLACE OR REMOVE ANY SHIELDING WIT'HOUT HP OR ALARA SPECIALIST CONCURRENCE."
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ACTIONS OF MANAGEMENT IMMEDIATE ACTIONS (CONT ' D) o ALL RWPS WERE REVISED TO STATE,
" ADVISE HP.
WHEN JOB SCOPE CHANGES."
o ALL PERSONNEL CHECKING OUT A SURVEY. METER WERE TO BE GIVEN ON-THE-SPOT TRAINING IN ITS USE.
o ALL SUPERVISORS OF CRAFTS WERE BRIEFED ON THE EXPOSURE INCIDENT AND THEIR RESPONSIBILITIES CONCERNING SHIELDING PRIOR TO BEING ALLOWED TO RESUME WORK.
O AN UPPER LIMIT TO THE NON-LICENSED OPERATORS DOSE WAS CONSERVATIVELY ESTABLISHED BY REENACTING THE INCIDENT UNDER HP SUPERVISION.
o THE NRC WAS NOTIFIED OF THE INCIDENT BY PHONE.
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ACTIONS OF MANAGEMENT ADDITIONAL FOLLOW-UP ACTIONS o
A MEMD FROM THE DIRECTOR, NUCLEAR PLANT OPERATIONS, RELATIVE TO TEMPORARY OR PERMANENT SHIELDING WAS ISSUED.
A TRAINING RECORD WAS ALSO GENERATED TO DOCUMENT ALL RADIATION WORKERS UNDERSTOOD THIS MESSAGE.
O ALL OPERATORS INVOLVED WERE COUNSELED.
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A WALKDOWN WAS CONDUCTED TO EVALUATE THE l
EFFECTIVENESS OF PRESENT BARRIERS TO HIGH RADIATION AREAS.
(A MODIFICATION PACKAGE HAS BEEN ISSUED THAT ADDRESSES THIS SUBJECT.)
o THE EXPOSED INDIVIDUAL WAS GIVEN SPECIFIC l
TRAINING ON THE USE AND LIMITATIONS OF SURVEY INSTRUMENTS.
O GENERAL EMPLOYEE TRAINING WAS REVISED TO INCLUDE FAILURE MODES OF SURVEY INSTRUMENTS.
o A LOCKED STEEL ENCLOSURE WAS INSTALLED ACROSS THE LEAD BRICK OPENING.
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ACTIONS OF MANAGEMENT ADDITIONAL FOLLOW-UP ACTIONS (CONT ' D) o REVIEW OF ALL FIELD PROBLEM REPORTS (FPR)
REGARDING RADIATION HAZARDS WAS CONDUCTED.
o APPLICABLE PROCEDURES FOR FILLING THE FUEL TRANSFER CANAL WERE REVIEWED AND REVISED.
o A LEAK DETECTION MECHANISM IS PLANNED TO BE INSTALLED WHILE THE LEAD BRICKS ARE REMOVED FOR THE REACTOR VESSEL SKIRT WELD INSPECTION DURING THIS OUTAGE.
CAUSES ROOT CAUSE o
LACK OF A GOOD METHOD FOR EARLY DETECTION OF WATER LEAKAGE PAST THE REACTOR CAVITY SEAL.
(DETERMINED USING MORT METHOD.)
CONTRIBUTING CAUSES o
REMOVAL OF SHIELDING WITHOUT AUTHORIZATION.
o FAILURE TO INFORM HP OF A CHANGE-OF-SCOPE IN WORK.
o FAILURE TO CHECK DOSIMETER DURING WORK PERIOD.
o LACK OF KNOWLEDGE AS TO THE INCORE DETECTOR POSITIONING AND ITS SIGNIFICANCE WITH REGARD TO LEAD SHIELDING.
o LACK OF KNOWLEDGE OF THE LIMITATIONS OF DOSE RATE INSTRUMENTS.
o FAILURE TO INCLUDE THE EXPOSED NON-LICENSED OPERATOR IN THE PRE-JOB BRIEFING.
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.O RECOGNIZED FAILURES AND ACTIONS TAKEN FAILURE #1 FAILURE TO LOCK,
- POST, BARRICADE, AND TO ISSUE A RADIATION WORK PERMIT TO CONTROL ACCESS TO A HIGH RADIATION AREA.
ACTIONS:
1.
A LOCKING MECHANISM FOR THE ENTRANCE TO THE HIGH RADIATION AREA WAS MANUFACTURED AND INSTALLED.
2.
THE ENTRANCE TO THE AREA IS POSTED WITH TEMPORARY WARNING SIGNS.
PERMANENT SIGNS ARE BEING MANUFACTURED.
3.
A FLASHING YELLOW LIGHT AND YELLOW AND MAGENTA R0PE BARRICADES ARE PLACED AT THE ENTRANCE TO THE HIGH RADIATION AREA.
4.
SIGNS STATING "D0 NOT PLACE OR REMOVE ANY SHIELDING WITHOUT HP OR ALARA SPECIALIST'S APPROVAL" AR'E POSTED AT THE RWP SIGN-IN DESK AND AB AND RB ENTRANCES.
RECOGNIZED FAILURES AND ACTIONS TAKEN FAILURE #1 (CONTINUED) 5.
ALL RWP'S WERE REVISED TO STATE
" ADVISE H.P.
WHEN JOB SCOPE CHANGES."
6.
AN INSPECTION OF THE PLANT WAS PERFORMED AND THREE AREAS OF LIKE CONCERN WERE NOTED.
ENGINEERING ACTION IS BEING TAKEN FOR THE INSTALLATION OF LOCKING MECHANISMS ON THE ACCESSES TO THESE AREAS.
THESE AREAS ARE POSTED.
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RECOGNIZED FAILURES AND ACTIONS TAKEN FAILURE #2 FAILURE TO ADEQUATELY INSTRUCT RADIATION WORKERS IN USE OF SURVEY METERS AND WHAT TO DO WHEN THE WORK CONDITIONS CHANGE.
ACTIONS:
1.
RADIATION SAFETY PROCEDURE, RSP-101, IS BEING REVISED TO STATE "IF DOSE RATE METER READS OFF-SCALE HIGH OR LOW OR HIGHER THAN ANTICIPATED, EXIT THE HIGH RADIATION AREA IMMEDIATELY AND CONTACT HEALTH PHYSICS."
2.
RADIATION PROCEDURE, ASP-106, IS BEING REVISED TO STATE "IT IS THE RESPONSIBILITY OF THE JOB SUPERVISOR TO INSURE THAT ALL WORKERS HE ASSIGNS TO PERFORM WORK ON AN RWP UNDERSTAND THE SCOPE AND HAZARDS OF THE WORK THEY ARE TO PERFORM WHILE IN THE RCA."
3.
A LONG TERM' ACTION WILL INCLUDE THE INITIATION OF A PRACTICAL FACTORS SIGN-OFF SHEET FOR RADIATION WORKER TRAINING.
SOME SIGN-OFFS WILL PERTAIN TO THE USE OF DOSE RATE MONITORING INSTRUMENTS.
RECOGNIZED FAILURES AND ACTIONS TAKEN FAILURE #3 FAILURE TO ESTABLISH ADEGUATE RADIATION PROTECTION, REFUELING, AND OPERATIONS PROCEDURES.
ACTIONS:-
1.
RSP-101 IS BEING REVISED TO STATE "IF IT BECOMES NECESSARY T0 EXCEED THE SCOPE OF' THE RWP TO PERFORM WORK OR IF WORK CONDITIONS DEVIATE FROM THOSE DESCRIBED ON THE RWP:
A.
STOP WORK; AND B.
CONTACT HEALTH PHYSICS."
2.
RSP-106 IS BEING REVISED TO STATE "IT IS THE RESPONSIBILITY OF THE JOB SUPERVISOR TO CONTACT HEALTH PHYSICS FOR AN RWP REVISION IF THE ORIGINAL SCOPE OF THE WORK HE DESCRIBED CHANGES."
RECOGNIZED FAILURES AND ACTIONS TAKEN FAILURE #3 (CONTINUED) 3.
HPP-106 IS BEING REVISED TO MORE CLEARLY STATE HEALTH PHYSICS RESPONSIBILITIES AND ACTIONS CONCERNING CHANGING WORK SCOPE AND RWP REVISION.
4.
RSP-101 IS BEING REVISED TO STATE "D0 NOT l
REPOSITION OR REMOVE PERMANENT OR PORTABLE-l LEAD SHIELDING WITHOUT HEALTH PHYSICS l
AND/OR ALARA APPROVAL."
1 1
5.
RSP-101 IS BEING REVISED TO STATE j
" REPOSITIONING OR REMOVAL OF LEAD SHIELDING FROM ITS INSTALLED LOCATION COULD LEAD TO I
PERSONNEL OVEREXPOSURE DUE TO SIGNIFICANT l
INCREASE IN DOSE RATE LEVELS."
6.
HPP-202 IS BEING REVISED TO INCLUDE AN APPENDIX LISTING KNOWN HIGH RADIATION AREAS IN THE REACTOR BUILDING.
THIS WILL FACILITATE POSTING.
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RECOGNIZED FAILURES AND ACTIONS TAKEN FAILURE #3 (CONTINUED) 7.
REFUELING PROCEDURES WILL BE REVIEWED AND
" RADIATION SAFETY HOLDPOINTS" INSERTED AS APPROPRIATE.
8.
OP-404 AND OP-406 HAVE BEEN CHANGE 0 TO INCLUDE REQUIREMENTS FOR A PRE-JOB BRIEFING AND SPECIFIC INSTRUCTIONS FOR MONITORING THE TRANSFER CANAL FILL AND SEAL PLATE LEAKAGE.
A PRECAUTION WAS ALSO ADDED WITH REGARD TO REMOVAL OR ALTERATION OF SHIELDING WITHOUT PROPER AUTHORIZATION.
NOTE:
INSTRUCTION ON RSP CHANGES WILL BE GIVEN DURING GENERAL EMPLOYEE TRAINING.
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