ML21067A182
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Description: c. 11
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Survey#: c::JOJ4 - '1303
Description:
.NGE"T.,rolt\.D~ sc,.,rye.~ Date:9 /;l.$ ll1u Tirue: ~7 6C, ~
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ZS-LS-107 Revision 0 Information Use Attachment 1 Apparent Cause Evaluation (ACE) for Condition Report (CR) No: CR-2014-001074 CR
Title:
Sig 2 Contamination Identified on the Ground During Waste Movement Evaluator: Robert Keene Date: 11/06/2014 Section I: Evaluation Problem When an 8-120 liner was loaded into an 8-120B Shipping Cask in the South Yard, Statement: contamination was spread to the ground then subsequently spread to other areas of the site.
Background On 9/24/2014, an 8-120 liner was loaded into an 8-120B Shipping Cask. The normal and Timeline process for shipping these liners from the South Storage Array since September of 2013 is detailed as follows. The rad vault lid is removed and set to the side using the crane. The liner is manually disengaged from the over-pack by retracting the clips and the liner is withdrawn into the T-Bell. The T-Bell is moved over just North of the rad vault storage array and placed down onto a tarp. The over-pack is inspected and any residual water remaining is removed. Typical water content has been less than a pint. The over-pack is then removed from the rad vault and placed inside a secondary enclosure (bag). The over-pack/bag combo is then placed inside of the Shipping Cask. The liner/T-Bell is then picked up and raised above the Shipping Cask. The liner is then lowered into the over-pack/bag combo and the over-pack locks re-engage. The bag is then sealed and the Shipping Cask lid and impact limiter are placed and cask is prepped for shipment.
The exterior surface of the liner is contaminated as it was under the water in the Reactor Cavity for loading. The interior of the over-pack is contaminated once coming into contact with the liner. The exterior of the over-pack is typically not contaminated. The use of a secondary enclosure (bag) started in September of 2013 and is required by the Shipping Cask Certificate of Compliance. This was a major change as prior to September of 2013 no secondary enclosure was required.
Several mock-ups were performed in 2013 with empty liner/over-pack combinations to determine the most ALARA method for performing shipments using the bag. One mock-up was performed with empty liner/over-pack not inside T-Bell and required 2-3 individuals coming into contact with the liner/over-pack for approximately 10-15 minutes to place the bag. The unshielded dose rates on the outside of the liners are typically 100 R/hr to 300 R/hr on contact. These dose rates made manual placement of the bag around the liner/over-pack unshielded (not in T-Bell) unreasonable. A second mock-up was placing the bag into the Shipping Cask and the empty liner/over-pack was lowered into the Shipping Cask. The bag would get caught on over-pack and be dragged down into the Shipping Cask, the bag also ripped on two separate occasions. Manual manipulation of the bag close to the liner/over-pack and failure of the bag by ripping would have led to unacceptable levels of dose and risk of secondary enclosure failure. This was determined to not be a suitable option. A final mock-up was performed by disengaging an empty liner from the over-pack and placing the over-pack into the bag and then placing both into the Shipping Cask.
Then personnel lowered the empty liner from the T-Bell into the over-pack/bag. This method was deemed the most ALARA and reasonable. Multiple mock-ups were 1
ACE-2014-001074
ZS-LS-107 Revision 0 Information Use performed using different methods for disengaging the over-pack clips until the most ALARA method was selected.
Risk of contamination spread was believed to occur during movement of liner inside the T-Bell while moving from storage array to ground and ground to shipping cask as the bottom of the T-Bell is open and the liner is contaminated. After performing several shipments contamination was identified only once. A sliver of metal containing approximately 1 µ-Curie of Co-60 was identified on the ground on 06/17/2014 during a similar shipment documented in survey 2014-2823. No other contamination had been identified aside from that event prior to 09/24/2014. The particle was treated as an anomaly and the process remain unchanged.
On 06/24/2014, the same process was used. The transfer was completed and the Shipping Cask and truck were surveyed using 100 cm2 smears and no contamination was identified. The truck and cask were then relocated to the NGET parking lot.
Normal follow-up surveys were performed of the ground where the transfer took place and contamination was found identified. Several small particles/slivers/pieces of metal containing 0.02 µ-Curies to 3 µ-Curies of Co-60 were only in a localized area around where the truck and Shipping Cask had been. More detailed surveys of the truck and Shipping Cask were performed using both 100 cm2 smears and large area smears. Approximately 60-65 particles/slivers/pieces of metal containing 0.001 to 0.02 Curies of Co-60 were identified. Some particles/slivers/pieces of metal were also identified in the travel path of the cask and truck between the South Yard and the NGET parking lot. All contamination was identified, captured and disposed of and contamination found was documented in surveys 2014-4298, -4303, -4541and FSS Survey 14-1074. FSS also performed walk-over surveys of adjacent areas to the travel path where personnel walk, parking lots inside and outside of the Radiologically Restricted Area (RRA) and the roadway outside the RRA. No contamination was identified on these surveys; therefore, no contamination was believed to have left the RRA.
On 06/29/2014, the same process was used again with some enhancements. The secondary enclosure (bag) was handled with more caution not to touch the inside of the over-pack. The prior shipment on 06/24/2014 the bag has allowed draping inside the contaminated over-pack. Subsequent handling of the bag was believed to be one of the causes of the contamination spread. The motion of placing the liner inside the over-pack was displacing the contamination. After loading of the cask, more detailed surveys were performed. Contamination was again found on the outside of the Shipping Cask, the truck and the ground around the truck. The cask and truck were decontaminated then moved away from the loading point but kept in the South Yard.
The truck and cask were then resurveyed and decontaminated until 100% of the surfaces were checked and cleared. The truck was then allowed to move to the NGET parking lot. The South Yard area was decontaminated and roped off as a Radioactive Materials Area until more thorough surveys were performed. The ground was 100% surveyed with direct survey instrumentation, large area smears, sticky rollers and magnetic rollers. All contamination was identified, captured and disposed of and the area was down-posted.
All liner shipment operations were stopped following shipment on 09/29/2014. The 2
ACE-2014-001074
ZS-LS-107 Revision 0 Information Use liners shipped on 09/24/2014 and 09/29/2014 had been stored in the south array for over 6 months. Earlier shipments were made after only a few weeks of storage or were shipped directly from Containment. This longer storage time allowed the contamination to dry out thus increasing its probability of dispersion. The mechanistic displacement of air when inserting the liner into the over-pack was the cause of the spread of contamination both on 09/24/2014 and 09/29/2014. Based upon this information, it was deemed no longer acceptable to separate the liner from the over-pack and reinsert the liner into the over-pack outside. One option was to move the Shipping Cask and liner/over-pack into Containment and perform all of the loading operations inside. This would take additional dose and time due to multiple handling operations associated with the liner. Another option was to attempt to place the bag directly into the Shipping Cask and lower liner/over-pack combination directly into Shipping Cask. Waste Operations used larger bags than were used in September of 2013 during mock-ups and subsequent shipments for both the 09/24/2014 and 09/29/2014 shipments. Waste Operations and RP personnel believed it was possible to try this method again without ripping the bags and without letting the bags get dragged down into the Shipping Cask. This new method was performed on three subsequent shipments with no contamination issues. This process will continue to be used for all future shipments.
Evaluation for The cause of the spread of the contamination was the action of inserting the liner into ACE the over-pack. This cause was not anticipated due to the same evolution being performed multiple times in the exact same manner with no similar issues. The change in condition of the contamination being less wet after so long and being so easily dispersible was not anticipated.
APPARENT CAUSE:
A3-Human Performance LTA B2-Rule Based Error C04-Previous success in use of rule reinforced continued use of rule EVENT CODE:
3E - Radiation Protection - Equipment or Area Contamination Event Evaluation for A small number of 100 cm2 smears were taken of the Shipping Cask and truck prior Contributing to movement to the NGET parking lot. A more thorough survey of the cask and Causes truck is always performed in the NGET parking lot due to lower background radiation levels as compared to the South Yard. No contamination has been identified in past shipments using the same process. Based upon past experience and no positive contamination results on preliminary smears the truck was allowed to move from the South Yard thus spreading the contamination. The contributing cause for the spread of the contamination is the same for the apparent cause of the release of contamination.
CONTRIBUTING CAUSE(S):
A3-Human Performance LTA B2-Rule Based Error C04-Previous success in use of rule reinforced continued use of rule Other Actions OTHER ACTIONS:
Warranted None Identified 3
ACE-2014-001074
ZS-LS-107 Revision 0 Information Use Section II: Extent of Condition The loading of the liner/over-pack into the 8-120B Shipping Cask and the use of the secondary enclosure (bag) is unique. There has been only one other incident in which contamination was identified during a similar shipment as mentioned in the investigation. However, that incident resulted in a single particle which was anticipated to occur as a possibility. The corrective actions taken will prevent further occurrences of this event.
OTHER ACTIONS:
None Identified Section III: Extent of Cause No other issues similar to this event resulted in the same Apparent Cause or Contributing Cause based upon review of other rad related events in the CAP database.
OTHER ACTIONS:
None Identified Section IV: Corrective Actions Immediate Actions Taken:
- 1. (Action): Surveyed South Yard, NGET Parking Lot, travel path of truck and adjacent areas, parking lots and roadways.
COMPLETED BY: Angel Smith DATE COMPLETED: 09/25/2014
- 2. (Action): Enhanced method of handling secondary enclosure to minimize spread of contamination.
COMPLETED BY: Angel Smith DATE COMPLETED: 09/29/2014
- 3. (Action): Stopped further shipments after 09/29/2014 until corrective actions could be identified and implemented.
COMPLETED BY: Robert Keene DATE COMPLETED: 09/29/2014 Planned Actions:
- 1. APPARENT CAUSE: A3-B2-C04-Previous success in use of rule reinforced continued use of rule.
(Action): Changed loading process of 8-120B Shipping Cask. Secondary enclosure (bag) is placed inside Shipping Cask and liner/over-pack is lowered into Shipping Cask. Liner and over-pack are no longer separated outside.
OWNER: Mike Wiskerchen DATE COMPLETED: 10/01/2014
- 2. CONTRIBUTING CAUSE: A3-B2-C04 Previous success in use of rule reinforced continued use of rule.
(Action): RP performs detailed survey of the Shipping Cask and truck prior to movement from the South Yard to minimize the possibility for spreading contamination.
OWNER: Robert Keene DATE COMPLETED: 10/01/2014
- 3. (Action): Distributed First Notification# FN-2014-477.
OWNER: Robert Keene DATE COMPLETED: 10/06/2014 4
ACE-2014-001074
Attachment 10 ZS-LT-100-001-001 Field Log Revision 1 Page_l_ofi Information Use Sample Plan No.: NIA Survey Area No.: 10200
Description:
Radiologically Restricted Area Old NGET North Parking Area, Heavy Survey Haul Road South of Security Guard Unit No.: 10202, 10203!10204, 10206, 10207
Description:
House Field Log: Date: 09-25-2014 Time: Observation or Comment: Technician 06:00 Morning meeting brief. Job Assignment Old NGET Parking Lot & Heavy haul TS/JG road. Follow-up Informational Survey Post Decon of Low Boy Truck/Cask in Old NGET Parking Lot (CR-2014-001074). To identify areas of elevated Activity.
12:00 Two minute drill. TS/JG Presource check meter: Model #2350-1, SIN 266656 with a 44-10 probe, SIN PR3117 50, cal due date 11119/2014 JG Presource check meter: Model #2350-1, SIN 266669 with a 44-10 probe, SIN PR3 l 17 56, cal due date 08/12/2015. JG 13:10 Found 28Kdpm/15.5 cm2 in Old NGET Parking Lot, removed And placed in bag pending evaluation. (Survey Unit 10203) TS 13:15 Found lOKdpm/15.5 cm2 in Old NGET Parking Lot, removed And placed in bag pending evaluation. (Survey Unit 10203) TS 13:23 Found 20Kdpm/15.5 cm2 in Old NGET Parking Lot, removed And placed in bag pending evaluation. (Survey Unit 10203) TS 13:40 Found 150Kdpm/15.5 cm2 on Sweepings Pile, removed And placed in bag pending evaluation. (Survey Unit 10202) JG 13:50 Found 3Kdpm/15.5 cm in Heavy Haul Road, removed 2
And placed in bag pending evaluation. (Survey Unit 10204) TS 13:55 Found 22Kdpm/15.5 cm 2 in Heavy Haul Road, removed And placed in bag pending evaluation. (Survey Unit 10204) TS 14:00 Found 1,500Kdpm/15.5 cm2 in Heavy Haul Road, removed 39 of 41
Attachment 10 ZS-LT-100-001-001 Field Log Revision 1 Page2of_a_ Information Use Sample Plan No.: NIA Survey Area No.: 10200
Description:
Radiologically Restricted Area Old NGET North Parking Area, Heavy Survey Haul Road South of Security Guard Unit No.: 10202, 10203 210204, 10206! 10207
Description:
House Field Log: Date: 09-25-2014 And placed in bag pending evaluation. (Survey Unit 10204) TS 14:02 Found 450Kdpm/15.5 cm2 in Heavy Haul Road, removed And placed in bag pending evaluation. (Survey Unit 10204) TS 14:07 Found S0Kdpm/15.5 cm2 in Heavy Haul Road, removed And placed in bag pending evaluation. (Survey Unit 10204) TS 14:13 Found 14Kdpm/15.5 cm2 in Heavy Haul Road, removed And placed in bag pending evaluation. (Survey Unit 10204) TS 14:18 Found 25Kdpm/15.5 cm2 in Heavy Haul Road, removed And placed in bag pending evaluation. (Survey Unit 10206) TS 14:20 Directed by Management to scan personnel travel paths prior to Shift Change from PM-7's in Old NGET Bldg. to the North Access Gate, and from the ENC East Door to PM-7's. All areas scanned prior to shift change with no detectable activity above background.
1600 Found an area of 450Kdpm/15.5 cm2 in Heavy Haul Road Unit 1 Trackway, removed and placed in bag pending evaluation. (Survey Unit 10207) JG 16:15 K.Nicholson relieved T. Schlueter scanning heavy haul road. KN 17:30 Placed all particles removed in RMA storage area pending evaluation. JG Note: Used Ludlum Model 3 SIN 284230 Cal. Due 9/15/2015 with 15.5cm2 probe to quantify all particles found. Upon removal of contamination, all JG Ted Schlueter James Green Supervisor Review: ~ ?/4,/1~ ""'
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Attachment 10 ZS-LT-100-001-001 Field Log Revision 1 Page 1 of 2
-- -- Information Use Sample Plan No.: _N_/A_ _ _ __
Survey Area No.: _10_2_0_0_ _ __
Description:
Inside and Outside Radiological Restricted Area Survey Unit No.: Class 3-various
Description:
lnformatiqn Only-Follow-up Scan survey on travel path Field Log: Date: 9-26-2014 (Friday)
Time: Observation or Comment: Technician 06:00 Pre-job brief to perform the following surveys: KN/JG/MS/RS/AH/TP
- Perform scan surveys inside the Radiological Restricted area of the cask transport vehicle travel path in response to CR-2014-001074 (Survey units 10221B, 10208, 10207, 10206, 10204, and 10203).
- Perform scan surveys of the cask transport vehicle travel path outside the Radiolo~ical Restricted area from the north security gate to Shtloh blvd (Survey unit 10214).
- Perform scan surveys of selected areas of the east and west parking lots, i.e. typical vehicle travel lanes, typical mcoming cask transport vehicle parking location (Survey unit 10214).
- Performed scan survey inside portions of the NGET and ENC buildings, and parking area east ofFAB shop.
06:00 Personnel participating in the survey activities included: Karen KN/JG/MS/RS/AH/TP Nicholson (KN), James Green (JG), instrument technicians Mike Simmon (MS), Tom Powell (TP), Rad-engineer Ron Shippee (RS), and the FSS supervisor Art Hammond (AH), along with laborer support.
07:00 All surveys performed with Ludlum Model 2350-1, utilizing the KN/JG/TP 44-10 (Nal detector) probe. Instruments pre-source checked listed:# 266657, frobe 308037, cal due 11-18-2014, # 266668, probe 311786, ca due 6-19-2015, #304718, probe 321891, cal aue 4-1-2015, #266669, probe 311756, cal due 8-12-2015, and
- 266656, probe 311750, cal due 11-19-2014.
07:30 Inside Restricted area scan survey area included the asphalt road K.i~/JG/RS/AH travel path, from the windsock on the north end, to the graveled heavy haul path north edge, and over to the south gate security access building. Background ranged 5k-13k (except in front of the radioactive storage area was 35k). All measurements performed using detector with collimator attached. All scan survey results were indistinguishable from background. No Particles found.
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Attachment 10 ZS-LT-100-001-001 Field Log Revision 1 Page_2_ of _2_ Information Use Sample Plan No.: _N_/_A_ _ _ __
Survey Area No.: -10200
Description:
Inside and Outside Radiological Restricted Area Survey Unit No.: Class 3-various
Description:
Information Only-Follow-up Scan survey on travel path Field Log: Date: 9-26-2014 (Friday) 09:30 Non-Restricted area scan survey area included the asphalt paved road KN/JG/MS/RS/AH way, beginning at the north security access to the site access barriers on Shiloh blvd. The scan background was 3.5k to 5k on the newer asphalt, and on the older asphalt background ranged from 5k-9k. No collimators were used. Results indistinguishable from background.
No Particles found.
11 :00 JG identified an 8k indication in the grass area near the VCC JG construction pad. Investigation of this indication resulted in no particies found.
12:25 Performed scan survey of the east and west parking lots. Scanned KN/JG/MS/RS/AH selected areas of the parking lot, i.e. vehicle travel lanes and typical incomin$ cask transport vehicle parking location. The background for the area 1s 3.5k-5k. No collimator used. No particles found.
Note: A scan survey was performed in the NGET bldg hallways, ENC bldg RS hallways, and the parkin~ lot east of the ENC F AB shop. The background for the area 1s 3.5k -5k. No collimator used. No particles found.
KN/Karen Nicholson JG/James Green MS/Mikes*
TP/TomPowe 39 of 41