ML20244C697

Insp Rept 70-1151/89-01 on 890130-0209.Violations Noted. Major Areas Inspected:Radiation Protection Programs for Assuring Personnel Exposures Maintained ALARA & Allegations Re Radiation Protection Activities

ML20244C697
Person / Time
Site:	Westinghouse
Issue date:	04/06/1989
From:	Collins T, Kuzo G, Lauer M, Potter J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
To:
Shared Package
ML20244C689	List: ML20244C687 ML20244C694 ML20244C697
References
70-1151-89-01, 70-1151-89-1, NUDOCS 8904200346
Download: ML20244C697 (24)

Text

,_ ,_ , - - - _ - _ _ - - - . - _ - _ _ _ . _ _ _ _ - _ _ - .

UNITED STATES r

['00to

'O$'- A NUCLEAR REGULATORY COMMISslON REGION li f E.~ S 101 MARIETTA STREET, N.W. ';

i-L 5 f ATLANTA, GEORGI A 30323 .)

% p$

j Report No.: 70-1151/89-01 i l

Licensee: Westinghouse Electric Corporation 1 Commercial Nuclear Fuel Division Columbia, SC 29250 Docket No.: .70-1151 License No.: SNM-1107 )

Facility Name: Columbia Plant Inspection Conducted: January 30 - February 3, 1989 and February 9, 1989 Inspectors: t. O b n b A,3 f1@

G. B'. Date Signed Ku T. R. Col}(ns.

o k 8 6M Da[eSigned Md7 M. T. Lau Date Signed Approved by:

J. P. Totter, Chief Date Signed i Facilities Radiation Protection Section

' Emergency Preparedness and Radiological Protection Branch Division of Radiation Safety and Safeguards

SUMMARY

l Scope J

This ~special, unannounced inspection involved review of licensee radiation protection programs for assuring personnel exposures were maintained as low ast

reasonably achievable (ALARA), and review of previously identified inspector followup items (IFIs) and allegations concerning radiation protection activities.

t Resul ts ,

Licensee activities demonstrated a strong commitment to the ALARA concept for personnel radiation exposure. Management was knowledgeable and involved in C activities conducted to reduce personnel exposure. Goals'for reduced personal exposure to airborne radioactive material concentrations were established.

Mechanisms existed to identify and trend data used to identify concerns or areas needing improvement to meet ALARA goals. Teams involving both workers and supervisors, identified root causes of noted ALARA concerns and subsequently ' recommended appropriate. corrective actions. Licensee actions L8904200346 890406

>PDR ADOCK 07001151 I C .. PDC

l l

l have resulted in an overall trend of reduced airborne radioactive l concentrations at work areas, and thus lower potential for personnel exposure. I Strengths in the radiation protection program impacting ALARA in a positive manner were noted for general employee training, audit programs, facility cleanliness, job pre-planning reviews and radiation work permit development, process control use, and routine air sampling programs. Weaknesses were ]

identified for the lack of technician training for respiratory equipment maintenance, limited documentation of personnel exposure investigations, absence of documentation for selected ALARA evaluation criteria action limits, and the potential need for an additional permanently assigned technical person to support daily radiation protection activities. In addition, a program weakness concerning the licensee's inability to conduct adequate surveys of airborne radioactive material concentrations from nonroutine sources was identified as noted by an apparent violation for failure to take adequate air samples in the Manufacturing Automated Process (MAP) area. An allegation regarding an employee's exposure to uranium material was reviewed and no violations of licensee procedures or 10 CFR 20 requirements were noted. In addition, three previously identified IFIs were reviewed and considered closed.

Within the areas inspected, the following violation was identified:

Failure to conduct sufficient surveys of airborne radioactive contaminants j in the Manufacturing Automated Process (MAP) area to evaluate the hazards '

present. Violation of 10 CFR 20.201(b) requirements (Paragraph 11).

1 i

?

l ,

\

o 1

REPORT DETAILS l'. Persons Contacted LLicensee, Employees  !

C #R. Birkland, Regulatory Affairs (RA) Engineer

• R. Fisher Senior Engineer H. Foster,' Regulatory Engineer

1. W. Goodwin,'. Manager, RA-

• 1. J.' Heath, Manager, Regulatory _0perations G. LaBruyere,: Manager, MAP Area

1. P. Loch,_ Plant Manager

1. E. Reitler, Manager, Regulatory Engineering

• C, Sanders, Manager, Nuclear MaterialsLManagement and Process' Records

T. Shannon, Radiation Engineering Technician Other _ licensee employees contacted during this inspection included engineers, operators, technicians, and administrative personnel.

-Nuclear Regulatory Commission

1. T. Decker, Acting Branch Chief, Division of Radiation Safety'and Safeguards

• Attended pre-exit briefing on February 3,1989

1. Attended exit on February.9, 1989

. 2. ManagementInvolvementwithALARA(83822)

a. ALARA Policy Corporate management's commitment to, and involvement with ALARA issues ~ for the Westinghouse, Columbia faciilty were discussed with selected licensee representatives. The corporate Environmental Affairs Group and Health Physicist have prepared and issued directives regarding ALARA policy for this facility. The following directives outlining corporate policy used to ' develop the site's ALARA program were reviewed and discussed.

Management Directive (MD) R-15,. Radiation Safety, dated August 1982.

MD E-55, Environmental Control, dated August 1982.

The directives required the development and implementation-of written policies and practices governing exposure to ionizing radiation to be consistent with the corporate policy and practices. The corporate policy included the commitment to provide safe and healthful working

2 j 1

1 and external environmental conditions by controlling exposure .to ionizing radiation to a level that is "as low as reasonably achievable." Furthermore, this commitment requires the installation, maintenance, and operation of the facility to be in accordance with recognized and . accepted radiation safety standards. The plant manager is designated responsibility to meet the directive commitments.

b. Management and Organizational Responsibility j The facility organization and management involvement in implementing the ALARA policy at the site were reviewea. The Regulatory Compliance Committee (RCC) serves as the site functional review group '

for ALARA issues as detailed in Section 3.1.2.5 of the license application. As specified in its charter, the RCC functions to review and assess the Columbia Plant ALARA program pertaining to occupational radiation exposures, radioactive materials released to unrestricted areas and related unusual occurrences. The RCC assesses the program through evaluation of ALARA program data trends identified and preparation of semi-annual ALARA reports. Input into the report regarding ALARA objectives at the facility is provided through the site functional groups involved with regulatory inspections, airborne reduction evaluations, and implementation of the proposed 10 CFR Part 20 requirements.

Westinghouse Columbia management's commitment to develop and maintain an effective ALARA program is established through. involvement in the RCC. Currently, the RCC is comprised of nine persons, including two regulatory affairs personnel and tne managers for the plant functional divisions including, Controller, Human Resources,.

Manufacturing, Technical Services, Materials, Plant ano Control, Regulatory Affairs, and Product Assurance. The Plant Manager serves as the Chairman, RCC. The involvement of management in the review and evaluation of problem areas appeared to result in an informed and coordinated effort to meet established ALARA goals. Selective interviews with licensee managers indicated a detailed understanding of current ALARA concerns and of the immediate and long term corrective actions initiated and/or proposed to meet the established goals. Upper level management's involvement in the ALARA program was identified as a program strength,

c. Program Implementation For ALARA concerns involving airborne particulate contaminants, a subgroup within the RCC, the Airborne Reduction Team (ART) reviews trend analyses, and airborne and personnel exposure data, to evaluate 4 and prioritize process areas requiring corrective actions to achieve '

established management objectives. The evaluation and corrective actions for identified areas of concern are assigned to subcommittees i consisting of an ART member and process area first line supervisors and managers. The involvement of these personnel in ALARA concerns

3 allows employees directly involved with a problem area to determine the " root cause" and to provide input regarding corrective actions.

The RCC meeting minutes from February 1986 to January 1989 were reviewed and discussed with licensee representatives. The committee met as required. The meeting minutes indicated that the majority of items reviewed were ALARA -issues identified by ART activities. The meeting indicated that the majority of ART established goals were met or exceeded. Review of selected ART meeting minutes indicated that actions were timely, goals established, and corrective actions thorough for areas of concern.

The daily implementation of the ALARA program is the responsibility of the licensee's management with support from the various service groups. All first line supervisors and their respective managers are

. evaluated in their involvement with ALARA concepts for airborne radioactive material reduction through objectives established in their performance management system program. Licensee l representatives stated that this. program has resulted in increased 1 employee awareness of ALARA issues for the specific work areas and increased requests for service group support, for example Regulatory Affairs assistance, when concerns were noted.

l

d. ALARA Program Evaluations The established criteria used to evaluate the ALARA concept at the facility were discussed and reviewed with licensee representatives.

Goals for these criteria are established by the Plant Manager, Regulatory Relations Group, or consensus of the RCC. During 1988, the identification of work areas requiring increased corrective action and management attention to comply with the facility i commitment to ALARA were based on the following criteria as measured during six month intervals.

1) Work station average airborne concentrations exceeding 25% of the 10 CFR Part 20, Appendix B, Maximum Permissible Concentration (MPCa) limits for a restricted area.

2) Work stations having 20 or more airborne spikes exceeding 100%

MPCa.

3) Work stations accumulating 500 MPCa-hours.

4) Work station MPC-hours breathed exceeding 25% MPCa.

During 1989, two of the established evaluation criteria were made more restrictive with the average MPCa required to be maintained below 20% and the frequency of spikes exceeding 100% MPCa reduced to 10 for each work station. The inspector noted that the policy of periodically reviewing and reestablishing the ALARA evaluation

<L 4

criteria and goals was considered a pro-active initiative to the site ALARA concept and was identified as a program strength.

Discussions with various managers and workers indicated that the use of these evaluation criteria for the ALARA program were not documented. In addition, the inspector noted that other criteria to evaluate the ALARA program status concerns have been monitored and trended for selected work areas, for example, the frequency of contamination events occurring in the Modified Automated Process (MAP) area. Licensee representatives agreed to review the need for formal evaluation and documentation of ALARA program indicators. The inspector noted that licensee actions regardin tracked as a NRC Inspector Fol?owup Item (IFI)g this issue'would and would be reviewed be during a subsequent inspection (70-1151/89-01-01).

e. Process and Procedural Modifications The inspector reviewed the incorporation of ALARA considerations into the new operations and/or procedures at the facility.

In regard to initial process development and design, Procedure RA-104, Regulatory Affairs Review Requests, Rev. 2, dated September 30, 1988, provides a mechanism for a Regulatory Affairs engineer to evaluate and provide input concerning HP and ALARA issues for proposed process additions or modifications.. This provides a mechanism for regulatory engineers to review or request process controls and other proposed designs in the new processes to enhance the ALARA concept at the facility. In addition, new procedures are prepared according to TA-002, Operating Procedures Style Book which requires review by regulatory engineering to evaluate HP and ALARA concerns. Subsequent to the implementation of the systems and procedures, the routine ALARA evaluation criteria are used to determine the adequacy of the systems and procedures as designed.

Excluding the MAP process area, all new system and procedures followed the above guidelines for ALARA considerations in their development. Licensee representatives stated that initial control and input for development of the MAP operations by onsite organizations were limited. This lack of control and initial input to the system was identified by licensee representatives as a deficiency which resulted in the ALARA concerns identified in Paragraph 11 of this report.

3. Audits of Radiation Protection Program (83822)

The inspector reviewed the licensee's in-house audit system to evaluate the ALARA program effectiveness and to correct deficiencies identified.

During these reviews the inspector determined that the licensee's program for auditing the Radiation Protection Program in regards to ALARA was described in procedure RA-102, Plant Inspection Program for Regulatory Compliance, Rev.1, dated November 3,1988. The inspector reviewed this

5 procedure and determined that thc licensee's program for auditing the Radiation Protection Program was both' a compliance audit and good work practices review to maintain personnel exposures ALARA. The licensee performs monthly audits from a well developed audit check-list as defined in procedure RA-102. The inspector selectively reviewed the audits performed during 1987 and 1988. The audit findings reviewed were programmatic in nature to an extent that correction of the findings would

- prevent increased contamination and airborne radioactivity levels. These findings were tracked and corrected in a timely manner to keep exposures ALARA. The inspector informed licensee management representatives that this program was considered a program strength.

In addition to the routine audits, licensee representatives stated that an independent audit of the radiation protection program has been scheduled.

A contractor has been selected to perform an independent evaluation of the current radiation protection organization and programs. In addition, the licensee's ability to meet proposed changes to 10 CFR Part 20 are to be reviewed. A vendor has been selected and the audit was scheduled for completion within the current year. The selection of an independent contract group to evaluate the radiation protection program was identified as a program strength.

4. General Employee Training (GET) (83822)

The inspector discussed ALARA training with licensee representatives and was informed that ALARA concepts were presented in various aspects of the Radiation Safety Training Program. The training program was outlined in the following procedures:  !

RA-105, Regulatory Affairs Indoctrination and Training, Revision (Rev.) 1, dated February 26, 1988.

RA-214, Radiological Protection Training, Rev.1, dated June 18, 1988.

Guide No. 24, Employee Orientation, Rev. 6, dated January 1, 1989.

Guide No. 42, Exposure of Fetus to Ionizing Radiation, Rev. 2 dated May 31, 1988.

The inspector determined by review of the above procedures, review of lesson plans, outlines of specific training programs, review of specific training tapes, and interviews with workers, that the licensee's training program was sufficient and detailed for the purposes of informing and instructing plant workers in controls to minimize exposure and that I workers were aware of ALARA concepts. ALARA concepts are presented in three specific training programs which are, but not limited to, (1) radiation safety orientation, (2) instruction concerning risks from occupational radiation exposure, and (3) instructions concerning prenatal radiation exposure. The inspector concluded that the licensee's ALARA training program was adequate and considered a program strength.

I l

{

j 1

i 6

]

i J

5. HealthPhysicsTraining(83822)

The inspector discussed health physics (HP) technician training with licensee representatives and was informed that at present no formal program had been established to train or retrain HP technicians in various aspects of radiological controls. The inspector was informed that a proposed training program for HP technicians had been under evaluation for several years. However, due to the limited time, resources, and other administrative concerns this program has not been implemented.

The inspector reviewed the proposed HP technician training program and concluded that adequate ALARA concepts were included in the proposed program. Licensee representatives stated that this program should have been implemented in 1988, but due to operational priorities and concerns, formal implementation was not completed. The licensee has ' established a revised goal for completion of this program in 1989. However, additional administrative concerns potentially delaying formal implementation have been identified. The inspector informed licensee management representatives that with these additional administrative concerns sufficient resources in the HP organization were not available to complete the evaluation and implementation of this program in 1989. Licensee management representatives acknowledged that the HP technician training  ;

program would not be implemented by the end of 1989. The inspector i concluded that the lateness of implementing a formal HP technician training i program to maintain and/or upgrade technician qualifications was considered a program weakness.

6. Health Physics Staff (83822)

The inspector discussed the staffing levels of the HP organization with licensee representatives and determined by review of worked performed by the HP staff in 1988, and discussions with HP personnel that a sufficient number of HP technicians were available to support routine and non-routine operations. The licensee has fourteen HP technicians with an average of approximately ten years experience, one HP supervisor, one HP manager and two students in training from local technical institutes. This complement is responsible for twenty-four hours per day, seven days a week coverage.

The inspector determined by review that the HP overtime worked by technicians for 1988 was only six percent.

In further discussions, the inspector determined that the HP Manager is on call twenty-four hours a day, seven days a week and frequently works considerable overtime either at, or away from the plant. Licensee management was aware of the HP Manager's workload but stated that, if needed, technical support could be provided by the Regulatory Affairs group and did not consider an additional technical position to be a priority item.

The inspector discussed this issue with management representatives and noted that even though the excessive workload was not impacting the safety level of the program, additional full time technical support could improve the review of radiation protection data and thus enhance the effectiveness i

l; . .;  ;)

lb L 7 J

L j L - -. -

L of'ALARA programs. ~Also, the formal HP technician' training program could.-

I' ' have been implemented in a timely manner'if additional _ technical support

- was - available. Licensee management representative acknowledged. the inspectors concern and. stated they would evaluate the need for additional-HP. technical support.

7. Respiratory Protection Program (83822)

The licensee's respiratory protection program was reviewed to evaluate its effectiveness in maintaining personnel exposures ALARA. The-inspectorL determined that the licensee's respiratory protection program was outlined:

in the following procedures:

RA-205, Respiratory- Protection, Rev.1, dated December 7,1988.

.RA-218, Respiratory Issuance Personnel Exposure, Rev. 1, dated December 14,_1988.05-011, Respiratory Test Facility Model 260 Respirator Fit Test Instrument,.Rev. 3, dated January 13, 1989.05-018, Respirator Overchecks, Rev. 4, dated February 3,1988.05-041, Respirator Fit Frequency, Rev. 4, dated January 13, 1989.

15-3350-01, HNS Operation of Q127 (TDA-100) 00P Penetrometer and Bench Tester, Rev. O, dated July 18, 1986.

NS-3320-02, Respirator Cleaning System - Nuclear Fuels Division, Rev.-0, dated March 28, 1988.

r4S-3350-03, Operation of the HNS Filter Respirator Test System, Rev.-0, dated Mi rch 27, 1989.

The inspecto, aetermined after review of the licensee's respiratory e protection prog > am as outlined in the procedures listed above, that the respiratory protection program was in accordance with appropriate guidance and regulations to maintain personnel exposurer ALARA.

The inspector concluded by review, observations, and discussions with licensee representatives that personnel were wearing respirators as required in controlled areas and that a sufficient quantity of respirators were available for use. The inspector also determined that the licensee's program for selection, fitting, training, and medical qualifications for selected personnel was adequate and in accordance with appropriate regulations.

During the review of the respiratory protection program, the inspector noted that personnel inspecting and performing maintenance on certain  !

respiratory protective devices had not received specific training as recommended. by NUREG - 0041, Acceptable Programs for Respiratory

8 Protection. The. inspector informed licensee management that vendors who supply respiratory protective equipment provide this specific training for personnel performing these tasks. Licensee management representatives acknowledged the inspector's concern and stated that the need to train

personnel performing maintenance on respiratory protectiv'e equipment would be evaluated.

The ' inspector ' also noted that specific procedures relative to the maintenance and. inspection of certain respiratory protective equipment

' were not implemented and approved -through the normal procedure approval cycle by specific licensee management personnel. The inspector informed licensee management representatives that although not a regulatory requirement, a more standard method to review and implement the respiratory protective equipment procedures was needed. Licensee management personnel acknowledged the inspector's concerns and stated that these procedures would be reviewed and implemented in a manner similar to other_ procedures.

During a review of requirements dictating respirator use, the inspector inquired as to ' the criteria used foi this decision. Licensee representatives stated that general practice was to require respirators when the area airborne concentration was one times MPC or greater,

~ however, this guidance was not established by formal procedure. Further interv4 tws of personnel by the inspector verified that this guidance was widely known and adhered to, and that the lack of proceduralization did not appear to result in. inadequate respirator use.. The inspector stated to licensee representatives that to assure proper administrative control over respirator use, specific criteria -for the use nf ' respiratory ,

protection equipment should be proceduralized. In addition, established  !

guidance should be expanded-to include the use of smearable contamination survey results as well as the ambient or potential airborne levels. The

. incorporation of this requirement into the applicable procedures will be tracked as an IFI and will be reviewed during a subsequent inspection (70-1151/89-01-02).

10 CFR 20.103(b)(1) states that the licensee shall, as a precautionary procedure, use process or other engineering controls, to the extent practicable, to limit concentrations of radioactive materials in air to levels below those which delimit an airborne radioactivity area as defined in 10 CFR 20.203.

The inspector discussed engineering controls with licensee representatives who stated that significant reductions in airborne radioactive material 4 concentrations had been achieved with the installation of numerous laminar flow ventilation units, beginning in 1987. These units were currently installed at selected pellet oxidation hoods, scrup cage Blue M hoods, and MAP area pellet grinders, slug presses and oxidation hoods. The largest decreases in average percent MPCa were observed at the Pellet oxidation

hood 4 and the MAP oxidation hood, observed reductions ranging from 31% to l

7% and 29% to 4%, respectively. These hood units represented " Phase I" of the laminar flow plan. As needed, Phase II would add a HEPA-filtered ventilation pickup at the operators' fcet with Phase III comprishig a e

j.

l 9

l l '

l completely enclosed unit. The use of engineered process controls to reduce airborne contamination levels was considered a program strength.

8. Radiation Work Permits (83822)

The inspector discussed the Radiation Work Permit (RWP) program with licensee management representatives and was informed that the RWP program was described in Regulatory Affairs (RA) procedure, RA-207, Radiation Work Permit, Rev. 4, dated December 8,1986. The inspector reviewed the RWP program prm-dure and determined that the controls and precautions specified in the procedure were adequate to protect the health and safety of plant wM iers.

Additionally, the inspector discussed with licensee management representatives the extent of pre-job reviews performed prior to issuance, and post-job reviews performed after termination of specific RWPs. The inspector determined by review of selected RWPs during 1988, that the licensee performed pre-job reviews on specific modifications of, and/or additions to, existing uranium processing, handling and storage operations. This program is described in licensee procedure, RA-104, Regulatory Affairs Reviews Request (RARR), Rev. 2, dated September 30, 1988. The inspector reviewed the procedure prescribing the types of reviews required for specific tasks and concluded this program appeared adequate in requiring specific controls and precautions for plant workers when performing certain tasks. The inspector reviewed selected RWPs and RARRs performed during 1988 and concluded that the licensee performed adequate reviews, and specified adequate precautions and controls to limit the spread of contamination and prevent increased airborne radioactivity.

During reviews of the RWP program, the inspector noted that the licensee does not perform post-job reviews after the work under an RWP has been completed. The inspector iiiformed licensee management representatives that post job reviews should be performed to evaluate the adequacy of controls and precautions . specified on the RWP's to keep personnel '

exposures ALARA. Licensee management representatives acknowledged the inspector's concern and stated they would evaluate this issue for implementation. The inspector informed licensee management representatives that the failure to conduct post-job reviews would be considered an ALARA program weakness.

9. Bioassay Program (83822)

In order to verify thct the methods used to limit exposure of individuals to radioactive materials in air are adequate, the licensee has instituted a bioassay program. Also,10 CFR 20.103(a)(3) requires the use of m"asurements of radioactivity in the body, mea'surements of radioactivity excreted from the body, or any combination of such measurements to i determine compliance with the requirements of 10 CFR 20.103. Policy the licensee's bioassay program was detailed in Regulatory dictating (RA) Procedure RA-204, Bioassay Program, Rev. 3, dated Affairs December 16, 1988, and requires that bioassays be performed in accordance

. 1 10 l with the - requirements of 10 CFR 20 regulations and Columbia Plant SNM license conditions. The bioassay program primarily utilized urinalyses and in vivo measurements with additional provisions for fecal analyses and nasal smears.

a. Urinalysis The licensee's urinalysis program is defined in HP Operating procedure 04-001, Routine Urine Sampling' Program, Rev. 5, dated December 16, 1988. Routine sampling frequencies ranged from once per year to twelve times per year depending on the probability of exposure and solubility of the uranium compound. The frequencies met, as required by the license application, the minimum frequencies outlined in Regulatory Guide 8.11, " Applications of Bioassay for Uranium," June 1974. . Some of the uranium compounds processed at the facility have effective half-lives of several hours, and thus have the potential of evading detection using a thirty day sampling frequency. The licensee utilized urinalyses primarily as a diagnostic aide to evaluate uptake rather than for identifying exposures.

The assurance of adequate identification of potential exposures is accomplished through several methods. An extensive air sampling program is employed with conservative investigation thresholds which require urine samples. Specifically, urine and fecal analyses are required for workers without respirators in areas in which a fixed air sample result exceeds 2.5 times the MPCa, for a previous eight hour shift, workers ingesting uranium, or for workers with nasal smears exceeding 150 disintegrations per minutes (dpm). Additional potential exposure identification methods include worker knowledge of the visual and irritant characteristics of the compounds and an aggressive leak detection program. In addition to using urinalysis sampling as a diagnostic tool, the licensee staggers collection of urine samples from individuals in the same work location throughout the 30 day sampling period to enhance the detection function of the urinalysis program. The inspector reviewed and discussed the the licensee's bases for not implementing a daily urine sampling frequency for transportable uranium compounds. Even though more i frequent sampling would be desirable, the health and safety of the workers did not appeared to be impacted by the monthly sampling frequency. The licensee's use of multiple indicators to identify potential exposures to personnel was considered an ALARA program strength.

The use of urinalysis results to evaluate the ALARA program were reviewed. A urine sample result exceeding 16 micrograms of uranium per liter (ug U/1) in urine required the lowest initial level 4 response. Progressive levels of response existed at 100 and 1000 ug U/1 urine. The licensee's ALARA Report for January 1,1988, thru June 30, 1988, detailed statistically significant upward trends, increases of approximately 0.2 ug uranium per liter urine per quarter

t 11 for the past two years, (January 1987 through December 1988), in the Rod, WRD, and PAP areas. However, all area averages were well below the : lowest action. limit of 16 ug U/1 urine. Causes for the trend-observed in the MAP area are discussed in Paragraph 11. The inspector noted that licensee actions to reverse this trend for urinalysis results in these areas were in progress.

The licensee uses an offsite vendor laboratory to perform'the routine and non-routine urine and fecal analyses. Through discussions with licensee representatives the inspector verified minimum detectable activity levels for the analyses were adequate. .The license application requires that this vendor be audited by the licensee every two years. The inspectors reviewed the most recent Vendor Audit Report, dated January 9, 1989, and verified that the areas reviewed and the extent of those reviews appeared adequate.

b. In Vivo Measurements The licensee currently conducts in vivo analyses utilizing a table-type lung counter in a shielded booth with.two 9 inch by 2 inch sodium iodide (Nal) detectors. The minimum detectable activity was approximately 70-80 ug U-235. The documented in vivo. counter

" start-up" study was reviewed and found to be thorough and well supported. To provide an independent evaluation of the accuracy and precision of the system, the licensee participates in a cross check program with a national laboratory using workers from the facility.

Past results typically showed the licensee having higher, more conservative in vivo res91ts than the national laboratory.

Possible upgrades being considered for the in vivo counting program were discussed with licensee representatives. Proposed to be included in the Strategic Implementing Plan is the purchase of a state-of-the-art GeLi invivo counter to improve the sensitivity of the' analysis. Also being assessed was the purchase and use of a new computer code for the calculation of lung burdens based on invivo count results. The licensee's effort to continually investigate improvements in this area was considered a program strength.

The in vivo analysis frequency utilized meets Regulatory Guide 8.11 requirements as per the license application. Analysis frequencies for individuals were outlined in In Vivo Operating Procedure 8, Frequency of In Vivo Counts, Rev. 4, deted January 13, 1989. The frequencies generally exceeded those frequencies suggested in Regulatory Guide 8.11 and ranged from four counts per year to two counts per year depending on work location. Approximately 600 individuals are in the routine invivo analysis program.

Approximately 2100 analyses were performed in 1988, with 595 positive, that is, greater than 80 ug U-235, results observed.

i

l 12 In Vivo Operating Procedure 4, Performing In Vivo Counts, Rev. 4, dated July 12, 1988, contains action limits for invivo results which were found to match those action limits required by the license application.. A confirmed result of 150 ug U-235 requires the lowest level of response and an investigation if the results are unexpected.

A result of 200 ug U-235 or greater requires the investigation to include fecal and urine samples, and restricting of the individual from entering or working in the controlled area. Restrictions may be lifted when the individual obtains two consecutive counts under 100 l ug U-235. The inspector reviewed the investigations of the individuals with two consecutive counts above 200 ug . U-235.

Approximately six cases were identified in 1988. Through discussions with cognizant licensee personnel, the inspector determined that many of the actions performed during the investigations either were poorly documented on the investigation form or were general and lacked details. The limited detail provided in the investigation form was identified as a weakness in the in vivo program. The licensee's actions will be reviewed during a subsequent inspection and will be tracked by the NRC as an IFI (70-1151/89-01-03).  !

A review of the ALARA Reports indicated that a significant 2.5 year upward trend of body burden results existed in the MAP area, calculated as 3 ug U-235/ quarter. A similar positive upward slope j was observed over the last 5 years in the Conversion area. However, licensee representatives stated that this Conversion area trend was partially due to changes in the assay technique initiated in 1986.  !

The two year trend in this area was still postive but the rate decreased to 1.3 ug U-235/ quarter. I

c. Fecal Analysis l

During the past three years, January 1986 - December 1988, seven individuals have received calculated uptakes equivalent to, or j exceeding 40 MPC-hours in a seven consecutive day period, based on ,

fecal analysis. The largest value observed was 102 MPC-hours as a 1 result of a December 9, 1988, incident involving a Chemical ,

Development technician. Four of the seven individuals were workers from the MAP area, an area where concerns with ALAP,A program implementation have been identified (Paragraph 11). The use of fecal analyses to evaluate these incidents was reviewed by the inspector and found to be adequate to evaluate potential exposure to airborne contaminants.

10. Air Sampling Program (83822)

The ability of the licensee to accurately determine the amount of airborne radioactivity present in the work area and the existence of a program to ensure that this determination leads to the mitigation of acute and chronic uptakes is indicative of a program operating under the ALARA concept. In addition, 10 CFR 20,103(a)(3) requires that for the purposes of determining compliance with the requirements of this section the i

f

-. . - - _ _ _ _ - _ _ _ _ ___ i

13 licensee shall use suitable measurements of concentrations of radioactive materials in air for detecting and evaluating airborne radioactivity in restricted areas.

The inspector discussed with licensee representatives, the structure and implementation of the program which provides for accurate and timely ,

detection of- elevated airborne areas. Approximately 260 particulate air samplers are located throughout the facility, excluding the Integral Fuel Burnable Absorber (IFBA) production area, and are changed once per shift.

Verification of the adequacy of the number and location of the samplers is achieved with a representativeness program and bioassay correlations both of which are discussed below. The recorded sample results are obtained by gas flow proportional counter analyses of each filter paper, repeated three times for one minute and then taking the average of the results.

Licensee representatives stated that a minimum detectable activity of approximately 10 dpm is achieved with slight fluctuations occurring as a result of background changes.

The license application requires that air samples be representative of the air breathed by the worker and that this representativeness be verified every two years for fixed samplers averaging less than 10% of the MPCa, and annually for all other samplers. The licensee's air sampling representativeness program is described in HP Operating procedure 06-008, Air Scmpling Representativeness, Rev. O, dated January 2, 1987. To verify-representativeness, a mobile air sampler is located within a six foot radius of the current sampler location and within the normal work area.

Photographs are made to show the current fixed air sampler, worker, and mobile sampler locations. The previous year's photograph is used to .

ensure that the mobile sampler location is varied from year to year. The  !

fixed air sample is considered representative if the mobile air sample result is within a three sigma range of the fixed air sample result. For i routine situations, mobile air samplers appeared adequate to determine fixed air sampler representativeness and this procedure was considered adequate. However, in some instances of non-routine airborne contamination sources, mobile air samplers would not verify representativeness for multiple sources resulting from unexpected contamination as was observed in the MAP area. MAP area bioassay data 1 were determined to be on an upward trend during the past 2.5 years.

However, an increase in fixed air sampler data were not observed even though the annual mobile air sampler study indicated fixed air sample l representativeness. A detail discussion of this inadequacy is detailed in Paragraph 11. Correlation between trends in bioassay and airborne concentrations sample as measured by fixed air samplers appeared to be consistent for all other work areas examined.

To further maintain exposures ALARA, the licensee conducts several early detection activities to identify airborne contamination in a timely manner, that is, provide preliminary indications of problems prior to completion of quantitative analyses.

__ - _ _ _ _ . _-__ _ __ _______ ___-_______-________ -__ - _- _ -_- _ _ _ O

t 14 I

During each shift, an HP technician is assigned to provide continuous coverage in the production areas. The HP technician duties included leak detection and air sampler observations. The sampler observations are used to detect discolored filter paper prior to the routine change-out thus aiding in early leak detection. The samplers are checked twice per shift with findings documented on a Current Shift Sample Check form.

Timeliness in the identifying elevated radioactive airborne concentrations is also accomplished with the "Early Airborne Program" in which all filter paper samples are " quick counted" to obtain airborne data prior to the following shift entering the area. At the beginning of each shift, the area supervisors receive data indicating potential elevated results during the previous shift. Airborne concentration data from the previous shift exceeding one hundred percent (%) of the MPCa and/or elevated results from the previous day exceeding 25% or 50% MPCa (depending on the area) are considered elevated. Using information on incidents contained in the shift log, information obtained during shift turnover, and input from the workers, the area supervisor is responsible for determining causes and initiating corrective actions. Causes and comments concerning elevated samples greater than 100% of the MPCa are documented on an Early Airborne Report as described in Regulatory Affairs Procedure RA-210, Radioactivity Airborne Investigations, Rev. 4, dated September 6,1988. The supervisor may request support from the HP group. This investigative support is documented on a Surveillance Coverage form. Selected Surveillance Coverage forms were reviewed by the inspector and found to include mobile / temporary and high volume impactor air sample data, smear surveys, and/or observations by the technicians.

The HP technician assigned to the production area for continuous coverage also is required to complete a Surveillance Coverage form once per shift of any area. The surveillance is conducted at random. This provides a cross check function for the routine surveillance program to ensure the validity and representativeness of the routinely collected data.

Additional quality control activities for the air sampling program were dictated by HP Operating procedure 05-056, Air Sample Integrity Verification, Rev. 5, dated December 16, 1988, which required that each shift technician changing the air samples to perform inspections of the air samplers during the changeout. In addition, once a week an identical overcheck inspection was performed on the samplers by another technician.

These inspection results were documented and included the verification of proper functioning and setting of the flow meters, proper insertion of filter papers, and the current condition of quick disconnects, fittings, and vacuum lines.

The inspector discussed the level of review and assignment of responsibility for folicwup and short term trending of elevated air samples. These activities were shared by the Regulatory Engineering and the HP Operations groups as dictated by various procedures. Additional  :

airborne concentration data review and followup of off-normal results were informally performed by both groups. Licensee actions provided for mul ti-level review, investigation, and followup of elevated airborne

. +

g-t 4 l '15

' samples to an extent greater than that required by procedures or' the .

license application.

A. review of two and five year average ~ area fixed ~ air sampler results from the main process. areas indicated no statistically significant upward trends. Licensee representatives stated .that based on increases in production and enrichment of the uranium processed during these. time-periods, airborne concentrations would have been expected to increase'37%

if all. Other mitigating variables remained the same.

The inspector' discussed with licensee representatives current activities underway for the implementation of proposed 10 CFR Part 20 revisions. The licensee . was aware of the possible significant ' impact - the proposed revisions will have-on the facility's air sampling program and' appeared to be initiating an adequate review of the logistical and financial impacts.

For. routine operations, 'the licensee's air sampling program was well structured and implemented, thus impacting the licensee's-positive ALARA commitments. However, an inadequacy was identified _in the area of nonroutine airborne sampling which is discussed further in Paragraph 11.

~11. Nonroutine Air Sampling (83822) 10 CFR'20.201(b) requires each licensee to make or cause to'be made such surveys.. as (1) may - be necessary for the licensee to comply with the regulations in 10 CFR 20 and (2) are reasonable under the circumstances to evaluate the extent of radiation hazards that may be present.

10 CFR 20.103(a)(3) requires for purposes of determining compliance with the' requirements of this section, suitable measurements of concentrations of radioactive materials in air for detecting and evaluating- airborne radioactivity in restricted areas and in addition, as appropriate,

- measurements of radioactivity in the body, measurements' of radioactivity excreted from the body, or any combination of such measurements as may be necessary for timely detection and assessment of individual intakes of radioactivity by exposed individuals.

In July of 1986, the licensee began using a new automated production  !

facility. referenced as the MAP area. Since its start up, numerous

operating and design' problems have caused unexpected airborne releases which resulted in significant high levels of contamination in the area.

.From discussions with licensee personnel and review of past biannual ALARA reports which contained in depth trend analyses, the inspector determined that nonroutine situations resulting in elevated uranium airborne concentrations in the MAP area occurred. The following issues regarding i this area were reviewed and discussed with licensee representatives.  ;

Elevated in vivo results from several workers required work j restrictions although the individuals' work area fixed air samplers  !

t

16 did 'not exhibit elevated airborne uranium concentration results for the corresponding time period.

For seven individuals exceeding 40 MPC-hours exposures in seven consecutive days during the period of June 1986 through January 1989, four were from the MAP area.

A November 20, 1987 study reviewed air sample spikes in the MAP area, cress referencing date and location of the elevated samples.

Although unexpected from initial routine fixed air sampler-representativeness studies, results indicated that situations existed in which elevated sample results in one area resulted in an elevated sample (s) at a distant (unrelated) locations ~ . In one instance, a-correlation was observed between samplers located on different floors and approximately 100 feet apart. 'In response to these correlations, ventilation and building design inadequacies were investigated and corrected. l i'

A significant increase (more than 250 survey results in July 1987, exceeding 25,000 dpm/100 cm2 or greater) was noted in contamination levels, as well as extensive use of respiratory protective equipment  ?

and the initiation of special decontamination efforts for the MAP i area, during this time period. i Licensee representatives stated that the increase in contamination events resulted from the startup of a pressurized pneumatic power transfer system during July 1987. The system was the source of numerous leaks and was

' subsequently shutdown for modifications.

The inspector discussed protective and corrective actions initiated in response to airborne concerns in the MAP area. The licensee began to i assess and implement corrective actions immediately upon identification of unusual contamination problems subsequent to startup of the MAP process.

Significant effort was expended by the licensee for immediate and long-term corrective actions. Immediate actions included mandatory use of respiratory protective equipment throughout the MAP area, increased emphasis on decontamination efforts, and increased radiation protection monitoring. Long-term actions involved changing to the manual transfer of process material between work stations, retraining of operators, and designing and implementing selective process engir,eering controls. The inspector noted that currently the licensee's actions have reduced potential personnel exposure to airborne contaminants to 6cceptable  !

levels.

The inspector inquired as to the supplemental air sampling initiated to obtain more representative samples in the MAP area during the MAP system startup problems. However, extensive, additional evaluations of the worker breathing zone air, such as that achieved though the use of individual ,

lapel air samplers or portable air samplers representative of the worker's breathing zones had not been conducted. The inspector noted that the above referenced issues indicated that the licensee's fixed air samplers I

17 l

were r, accurately representing the actual airborne uranium concenttsions' breathed by all' workers in the MAP area. In addition, numerous examples of workers without breathing zone samples cleading areas-of. contamination . were documented. ,The inspector noted that, ahbugh workers were using respiratory protective- equipment,: accurate breathing zone air samples .for the workers were required to properly evaluate-the potential exposure. . The lack of a program to . evaluate airborne contamination resulting from non-routine sources was considered a program weakness.

The inspector informed licensee representatives that failure to make.

adequate breathing zone surveys of particulate airborne radioactive contaminants for personnel working near and/or cleaning non-routine sources of uranium contamination in the MAP area was identified as an apparent violation of 10 CFR 20.201(b) requirements (70-1151/89-01-04).

12. Facility. Tours i During the inspection period, the inspector selectively.. toured licensee facilities and interviewed workers to evaluate the degree of integration of ALARA concepts into- the licensee's radiation protection program. The following radiation protection items were noted and/or discussed with licensee representatives:

The radiologically controlled area (RCA) change rooms were orderly and clean. A well-defined method for changing into and out of protective clothing' was established and adhered to, thus minimizing the potential for the spread of contamination from the process areas.

Temporary containment structures for maintenance jobs which may create extensive airborne contamination were used extensively.

Cleanliness in the main process areas was maintained by the workers.

Leaks in the process area were minimal.

Floors were being resurfaced to facilitate any required  ;

decontamination efforts.

Remote monitoring video cameras were used to audit the performance of personnel surveys conducted by workers leaving the RCA. Improvements in licensee performance in this area were noted.

13. Allegation Followup (99014)

a. Allegation (RII-89-A-006)

The alleger stated that during October 1986, he had been over-exposed to airborne radioactive (uranium) materials while working at the Westinghouse, Columbia facility. The resultant over-exposure occurred as result of work conducted while cleaning the Torit dust i

m_____________._._

o

p. .

[.

18 collectors in the process area. The exposure resulted in the worker's lung burden exceeding 200 ug U-235, And sub;cquently, the worker was restricted from the RCA. In addition, the event resulted in significant changes to the routine Torit filter cleaning procedures. During review of his in v.ivo (lung burden) data with a NRC representative, the alleger stated that the current .in vivo results differed from the original values he observed immediately following completion of each analysis. The alleger was concerned.

that the licensee's evaluation was inadequate.

b. Discussion Interviews with the alleger were conducted during the week of Jarnuary 30, 1989. The worker could not reca'l a spec.ific event or set of events which could have resulted in the alleged over-exposure. ,

tiowever, he believed that the exposure was the result of Torit filter cleaning operations in the process area. The employee stated that he could not recail any anomalous occurrences while performing this task and that he followed the radiation protection and HP practices, and used protective clothing, and respiratory protective equipment required for conducting the operation. All other procedure requirements were followed and no unusual incidents were noted at the time. The inspector verified that the alleger was properly trained in respiratory protection equipment use, and radiological protection practices and procedures utilized to perform the job.

The procedure ust.i y the alleger to conduct the Torit filter clean out operations was reviewed and discussed with licensee personnel.

Licensee Chemical Operating Procedure (COP) - 814320, Servicing of Torit Dust Collectors and Absolute Filters, dated December 17, 1985, was utilized to conduct the referenced operation. The inspector reviewed the radiological protection criteria and special precautions stated in the applicable procedure with criteria listed in the current revision of the procedure, dated August 29, 1986. No significant changes regarding radiological protection and special precautions were noted.

1 The inspector discussed with both the alleger and cognizant licensee i representatives, the alleger's in vivo analyses results from January 1976 through November 29, 1988. 'eview of the in vivo results indicated positive results were tusured prior to the October 1986  !

data. For 1985, the employee's i' vivo analysis results ranged from 85 to 194 ug U-235, however, these values did not require restriction  ;

from the RCA' During a routine analysis conducted on October 19, 1986, in vivo data exceed 200 ug U-235, thus resulting in the  !

employee's restriction from the RCA. In addition, in vivo analyses I conducted subsequent to the restriction indicated values requiring  !

continued restriction until mid-year 1988. During the time, the employee was not exposed to any uranium compounds during the performance of alternate job tasks. In addition, in vivo analyses for the worker were conducted by an independent facility in  ;

I

[

19 L  :

1 i

September 1988. Results ranged from 25.7 to 70 ug U-235 for' the Worker. These results were. compared and used to substantiate to data-

.obtained by the licensee during June through November 1988, _ values ranging from 21 to 142 ug U-235.

j Guidance outlining licensee actions following confirmation ' of a positive in vivo analysis :is detailed in In Vivo Procedure, Number 4, .

Performing 11n Vivo Counts, dated January 1,1987. .The inspector L verified that the guidance contained in this procedure was identical

. to controls 'in effect at the' time of the allemr's restriction. The L worker's restriction, frequency of in vivo r w yses, and collection of both urine and fecal samples met procedurai requirements.

The alleged change to the employee's in' vivo results were discussed with licensee representatives. The alleger stated that many of the-values-appeared to~ have been reduced relative tc the data observed at -

the completion of each analyses. The alleger ,ould not' provide.a specific namole. From discussion with cognizant licensee representatives, the'inspe: tor. determined that the value observed by the; employee at the time of each analysis was preliminary, and the -

adjustments were made for the weekly background determinations prior to calculating the final values reported. The alleger's original in vivo results' and background adjustments conducted were not available for review, however, recent data = regarding this issue were reviewed to verify the'_ licensee's policy regarding this concern.

The employee's concerns regarding. the accuracy of the .in vivo analyses were reviewed and discussed with licensee representatives.

.The frequency and methods of calibration appeared adequate. Routine checks are made to verify consistency of. equipment performance. In addition, results of the licensee's performance in an in vivo analytical measurement cross-check program with an independent-facility conducted from 1986 through 1988 were reviewed. In general, 1 the licensee's results were more conservative. -Reasons for the differences observed were not c:etermined. 1 The potential for exposure to evaluated airborne uranium i concentrations during the time interval between the June 11, 1986,  !

and the October 2,1986 in vivo analysis which required restriction of the employee was evaluated by the inspector. The alleger's daily assigned MPCa-hours from June 1986 through October 70, 1986, did not exceed 5 MPCa-hours, a maximum value of 4.41 MPCa-hours listed for l June 12, 1986. The quarterly exposures were reported as 38 49 and ,

43 MPCa-hours for the first through third quarters of 1986, respec-  !

tively, of 1986. No values exceeded the regulatory limits requiring an evaluation or which denote a potential over-exposure to airborne contamination.

i

.c

• 20

c. Finding The alltegation was partially substantiated in that the original in-vivo results were modified by the licensee. However, the adjust n'ents were required to incorporate the appropriate background data into the final results reported and were not considered safety significant. The other alleged issues were not substantiated. No s significant changes to the radiological safety practices in the l referenced procedure, as a result of the alleger's exposure /restric-tion, were observed. In addition, licensee actions appeared to '

follow established procedures and no violations of 10 CFR Part 20 limits for exposure to airborne radioactive materials were noted.

14. Review of Previous Inspection Followup Items (92701)

a. (Closed) IFI 70-1151/88-03-01: Improper Storage of Respiratory Protection Equipment.

During a previous audit of the facility corducted during March 1988, j the inspector observed clean respirators stered in barrels. At that time, the potential for this storage method to deform the respirators and to potentially result in improper worker t 't was noted. The inspector verified that the licensee now provide,i individual storage units to maintain individual respirators prior tc use.

b. (Closed) IFI 70-1151/88-13-04: Documentation for the Administrative Control of Staggered Urinalysis Sampling.

A previous- inspection report documented that license conditions required monthly urinalyses to be conducted for workers in selected areas. The report noted that the licensee staggered collection of the urine samples from workers in each area, with a minimum of one sample collected per week for each area during the initial three weeks of each month. This staggered schedule was utilized to provide an improved and more thorough, relative to a s%gle sample day, evaluation for the potential uptake of uranium compounds by workers during the month. However, no formal procedure documented this practice. The inspector noted that Regulatory Operations (R0)

Operating Procedure 04-001, Routine Urine Sampling Program, Rev. 5, dated December 16, 1988, was revised to require urine samples to be collected each week during the first three weeks of the month for q individuals working in areas requiring monthly samples. '

c. (Closed) IFI 70-1151/88-13-05, Unique, Durable Identification of Airline Pressure Gauges. <

Specific licensee procedures required the inspection and calibration l of cylinder pressure gauges used to supply airline respirators. A  !

previous inspection identified inadequacies in the method used to I identify these gauges. The inspector verified that brass tags i

l

> . l

21 P

stamped with an appropriate identifying code had been attached to the gauges.

15..ExitInterview(30703)

The inspection. scope and findings were summarized on February 9,1989, with those persons. indicated -in Paragraph 1 above. .The inspector described the areas inspected in detail. Strengths in the licensee's ALARA program were noted for management's commitment to implementing the ALARA concept throughout the facility. .The establishment and tracking of goals, and the continual reevaluation of those goals were viewed as very positive responses to the ALARA program. Additional strengths in the program were noted for training, audits, job pre-planning reviews and RWP development, process control use and the routine air sampling' p'rogram.

Identified ALARA' program weaknesses included lack .of training .for HP technicians'; performing respiratory equipment maintenance, limited personnel exposure investigation documentation, absence of documentation . .

of ALARA program evaluation criteria action limits, and the potential need 1 for additional technical ' support to review the radiation protection program implementation. An additional program weakness concerning the licensee's inability to conduct adequate surveys of-airborne radioactive ,

material: concentrations from nonroutine sources was identified and '

resulted'in an apparent violation of 10 CFR 20.201(b). survey requirements for the MAP area. The inspector detailed the findings as noted below.

The inspector noted that an allegation regarding an employee's exposure to uranium materials continued to . be- evaluated and the findings would be detailed in the. final inspection report. In addition, three previously identified IFIs were reviewed and considered closed. )

r The licensee acknowledged the inspector's comments. The. licensee did not identify:as proprietary any-of the material provided to or reviewed by the

' inspector during the inspection.

^

l Item Number Description and Reference )

1 70-1151/89-01-01 IFI: Evaluation and documentation of criteria utilized to assess the l ALARAProgram(Paragraph 2.d). I 70-1151/89-01-02 IFI: Establish and document criteria for respiratory protection equipment use (Paragraph 7).

70-1151/89-01-03 IFI: Improve details provided for in vivo investigation documentation (Paragraph 9.b).

l l

l h

r. . : ..

,,-- a s 22 L.

t 70-1151/89-01-04 =VIO: -Failure to make adequate-breathing zone surveys of-particulate airborne radioactive l-contaminants for personnel working near and/or cleaning nonroutine sources of uranium contamination in the MAP area (Paragraph 11),

i l

l s

l t

i i

i

___ __.