View source for A06006, Provides Clarification of Issues Raised During 860904 Enforcement Conference & Insp 50-213/86-22 Re Radiation Worker Overexposure Incident.Health Physics Technician Failed to Perform Satisfactorily Due to Inadequate Training

{{Adams
| number = ML20210H874
| issue date = 09/11/1986
| title = Provides Clarification of Issues Raised During 860904 Enforcement Conference & Insp 50-213/86-22 Re Radiation Worker Overexposure Incident.Health Physics Technician Failed to Perform Satisfactorily Due to Inadequate Training
| author name = Opeka J
| author affiliation = CONNECTICUT YANKEE ATOMIC POWER CO.
| addressee name = Murley T
| addressee affiliation = NRC OFFICE OF INSPECTION &amp; ENFORCEMENT (IE REGION I)
| docket = 05000213
| license number = 
| contact person = 
| document report number = A06006, A6006, NUDOCS 8609260358
| document type = CORRESPONDENCE-LETTERS, INCOMING CORRESPONDENCE, UTILITY TO NRC
| page count = 5
}}

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  .I 1 CONNECTICUT YANKEE ATOMIC POWER COMPANY B E R L I N. CONNECTICUT P O BOX 270 HARTFORD. CONNECTICUT 06141 4270 TELEPHONE 203-665-5000 t
September 11, 1986 c                                  Docket No. 50-213 A06006 Dr. Tnomas E. Murley Regional .^ 16inistrator Region I U.S. Nuclear Regulatory Commission 631 Park Avenue King of Prussia, Pennsylvania 19406 Gentlemen:
Haddam Neck Plant Supplementary Information Regarding I&E Inspection 50-213/86-22 This letter provides clarification on some issues that were raised at the September 4, 1986 Enforcement Conference on the radiation worker overexposure incident at the Haddam Neck Plant.
Subsequent internal review of the proceedings of the conference have led us to conclude that this clarification is necessary to provide you with a full appreciation of our evaluation of the incident, and the corrective action that we plan to use to prevent recurrence.
       " Sacrificial" PIC In response to an NRC question asked at the meeting, the Radiation Protection Supervisor (RPS) indicated'that he was not aware of the use of the " sacrificial" PIC. While this is true, as a stand alone statement, it can be misleading.
The use of dosimetry in excess of that specified on the RWP is a fairly common practice at Haddam Neck for work involving high levels of contamination. This discretionary dosimetry is used by the Health Physics technicians as a means of monitoring the worker's exposure and is effective from both ALARA and contamination control perspectives. The fact that this practice existed was both known to and condoned by Health Physics supervision.
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Supervision was not aware, however, that the use of discretionary dosimetry had degraded into the practice of using " sacrificial" dosimetry. The importance of the distinction between discretionary and " sacrificial" is illustrated by the Health Physics technicians " definition" of the latter.   " Sacrificial",
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in the context of the statements made by the two technicians involved in this incident, can'best be characterized as
     " unofficial". This is the reason that they did not invoke the lost dosimetry procedure (RAP 6.4-12) when the PIC was discovered to be missing. Connecticut Yankee Atomic Power Company (CYAPCO) recognizes that there can be no such thing as " unofficial" dos'imetry. When dosimetry is placed on a worker for the purpose of controlling his exposure, it is " official". The concept of "sacrifical" dosimetry has been reviewed in depth with the Health Physics department. The fallacy of the concept, along with its potential consequences, has been demonstrated to them during our review of this incident.
The fact that Health Physics supervision was unaware of the use of " sacrificial" dosimetry was used by one NRC questioner at the conference as an indication that supervision did not adequately monitor the technician's steam generator activities. It is difficult to contest this conclusion given the fact that an overexposure did occur. We note, however, that the shift from the use of discretionary to sacrificial dosimetry on the part of the two technicians involved was a subtle one, not easily discerned by the normal supervisory monitoring which did take place. In fact, Health Physics supervision made daily tours of the various radiological work areas and one had occurred a few hours before this incident. The difficulty involved in detecting this practice was further compounded by the fact that the use of sacrificial dosimetry was not universal among technicians. Most technicians were using the discretionary dosimetry practice.
Root Cause Analysis CYAPCO maintains that our initial assessment of the root cause of this event is correct. We may not, however, have provided sufficient details of our reasoning to you at the conference to allow you to derive the same conclusion. We also opted to not specifically list the causes which we consider to be contributory, although they were included by inference in the corrective action sections of our prepared material. In order to give you a more complete view of our evaluation of this incident, a synopsis of our root cause analysis and the associated corrective action is included here.
In our investigation and analysis of this event, we considered many potential root causes for this incident including:
o   inadequate first-line supervision o   inadequate qualifications o   inadequate training 1

   , 1 o        inadequate procedures o        failure to follow procedures o . inadequate surveys o        inadequate supervisory oversight a-The conclusions that we reached on the contribution that each of
       .these items made to the incident, along with the corresponding corrective action, are given below.
4 We have concluded that inadequate first-line supervision was contributory to this event in that the Health Physics technician, who had been temporarily upgraded to supervisory status, failed to perform satisfactorily as a supervisor.           Instead, he had become actively involved in performing the camera monitoring work.         Immediate corrective action took the form of a directive issued by the Radiation Protection Supervisor to all upgraded technicians informing them that they were to perform supervisor duties only unless specifically directed by him to provide job coverage.         Long-term corrective action will involve training in work direction and supervisory skills for technicians who are periodically upgraded. Both of these corrective actions are listed, albeit in cursory fashion, on the prepared material that we supplied to you at the conference.
Inadequate qualification was not considered to be contributory to this incident. Both Health Physics technicians involved in this incident are Senior Technicians who exceed the requirements of the applicable ANSI standard, which we believe to be an adequate standard.
Inadequate training was deemed to be contributory to this incident.        Specifically, interviews with the technician who was controlling the worker on the steam generator platform l       indicated that the practical training he had received in
;      performing stay time calculations for work in an area where the dose rate varied widely (from 50 mrem / hour to 20 Rem / hour in this case) was not totally adequate. Clearly, supervision was also at fault for not ensuring that the technician was properly trained                      ,
for this task before expecting him to accomplish it. As a result                     '
i      of this weakness, the technician relied on what proved to be an erroneous correlation between the work performed by a previous platform worker and the work performed by the overexposed worker.
In fact, the movements of the two workers through the large radiation gradients present in the work area were markedly different. The short-term corrective action taken on the day of the incident was to mandate the use of self-alarming integrating dosimeters for all steam generator platform work. While this did
;       not specifically address the training problem, it did, in the                        i
!       short-term, ensure that poor stay time calculations did not cause                    l 4
additional exposure problems. The long-term corrective action, as stated in our prepared material, will involve the addition of                     i practical training exercises (such as stay time calculations in

    . l large gradient radiation fields) to our retraining program. This training upgrade will include the use of demonstrative examinations.                                     ,
Inadequate radiation surveys were also deemed to be contributory to this event. Clearer radiation surveys could have helped prevent this incident by more clearly defining the areas of high and low dose rates. The affected worker could have minimized his dose had it been clearer to him what spots to avoid. Work areas with high dose rates and high dose rate gradients should be carefully surveyed, the results clearly indicated on survey sheets and reviewed with the worker and health physics technician prior to entry. In addition, " intermittent surveys" will be more clearly defined. This will be done in the near future.
CYAPCO has concluded that a root cause of this event was failurr-to follow procedures. This is based on the fact that although there were procedural requirements in place that required etay time calculations and periodic PIC monitoring, the technician involved failed to perform them. One could speculate that the technician was inadequately trained on the importance of these requirements, but the technician's own actions undermine this position. This is evident from the fact that he did pull the worker out of the area to read his PIC. It is also evident by the rough correlation he used in lieu of a stay time calculation.
Finally, it is evident by the fact that the two technicians rationalized their failure to invoke the lor.t dosimetry procedure by considering the lost PIC as being "sacrifical". The technicians involved knew that something was not right, but they chose to allow the worker to return to work. While they may not have been aware of the exact procedural requirements by section and paragraph, their actions indicate that they were aware of what they were supposed to do, but they failed to do it.
The short-term corrective action for this failure involved disciplinary action for the individuals involved and dissemination of the lessons learned from the incident to the other technicians. The long-term corrective action will include review of the lessons learned from the incident with all Northeast Utilities Health Physics personnel and a new emphasis on procedural compliance as discussed in the next section.
Insufficient health physics supervisory attention was also found to be a significant contributing factor in that supervision did not ensure the technician assigned was capable of adequately performing the assigned task. Although tours were regularly made, closer monitoring of stay time calculations and radiation surveys could have prevented errors in these areas. In addition, the use of the upgraded technician to monitor the TV cameras, reducing his supervisory effectiveness, was condoned by supervision. However, the most significant error (the use of a
         " sacrificial" PIC) would probably not have been picked up with any reasonable amount of supervisory attention dee to the subtle l

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nature of this inappropriate practice.            Corrective action will consist of more effective supervisory involiement, particularly when a person is assigned to an unfamiliar and complex task.
Generic Implications As part of station management's review of this incident, the question was raised, "Do we have a generic problem with procedural compliance at Connecticut Yankee?" As stated in our prepared material, we approached this question by. reviewing the various plant performance indicators available (SALP Reports, NRC I&E Reports, and INPO Evaluations) to determine the extent procedural compliance affected our ratings. We concluded that there was a strong correlation.
Based on this review, we concluded that our procedures generally contained adequate guidance, but that not all workers were always following this guidance. We, therefore, have resolved to strictly enforce our Station Policy 94 (Disciplinary Action). We intend to send a signal to all employees and contractors alike that procedural compliance is expected and that failure to comply will result in disciplinary action.
More effective supervisory involvement in the critical activities of plant personnel will provide greater opportunities for uncovering problems similar to these, as well as convey to plant personnel a sense of importance in what they are doing and a sense of shared responsibility between them and their supervisors.
Conclusion We trust that this letter has provided you with a better appreciation of the depth of our evaluation of this incident and the adequacy of our corrective action. We believe that we have made significant efforts in both of these areas. It should also be noted that Millstone Nuclear Power Station will be reviewing their procedures and practices for any similar weaknesses and implementing any corrective actions determined to be appropriate.
We would welcome the opportunity to discuss these actions further if you have additional questions.
Very truly yours, CONNECTICUT YANKEE ATOMIC POWER COMPANY J . \t. ) Ope kak)               !
Senior Vice President b*.      I  - . 5 [ [,
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