Failure to Follow Procedures When Working in High Radiation AreasML031250056 |
Person / Time |
---|
Site: |
Beaver Valley, Millstone, Hatch, Monticello, Calvert Cliffs, Dresden, Davis Besse, Peach Bottom, Browns Ferry, Salem, Oconee, Mcguire, Nine Mile Point, Palisades, Palo Verde, Perry, Indian Point, Fermi, Kewaunee, Catawba, Harris, Wolf Creek, Saint Lucie, Point Beach, Oyster Creek, Watts Bar, Hope Creek, Grand Gulf, Cooper, Sequoyah, Byron, Pilgrim, Arkansas Nuclear, Three Mile Island, Braidwood, Susquehanna, Summer, Prairie Island, Columbia, Seabrook, Brunswick, Surry, Limerick, North Anna, Turkey Point, River Bend, Vermont Yankee, Crystal River, Haddam Neck, Ginna, Diablo Canyon, Callaway, Vogtle, Waterford, Duane Arnold, Farley, Robinson, Clinton, South Texas, San Onofre, Cook, Comanche Peak, Yankee Rowe, Maine Yankee, Quad Cities, Humboldt Bay, La Crosse, Big Rock Point, Rancho Seco, Zion, Midland, Bellefonte, Fort Calhoun, FitzPatrick, McGuire, LaSalle, 05000000, Zimmer, Fort Saint Vrain, Shoreham, Satsop, Trojan, Atlantic Nuclear Power Plant, Skagit, Marble Hill |
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Issue date: |
06/10/1986 |
---|
From: |
Jordan E NRC/IE |
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To: |
|
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References |
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IN-86-044, NUDOCS 8606040010 |
Download: ML031250056 (5) |
|
Similar Documents at Beaver Valley, Millstone, Hatch, Monticello, Calvert Cliffs, Dresden, Davis Besse, Peach Bottom, Browns Ferry, Salem, Oconee, Mcguire, Nine Mile Point, Palisades, Palo Verde, Perry, Indian Point, Fermi, Kewaunee, Catawba, Harris, Wolf Creek, Saint Lucie, Point Beach, Oyster Creek, Watts Bar, Hope Creek, Grand Gulf, Cooper, Sequoyah, Byron, Pilgrim, Arkansas Nuclear, Three Mile Island, Braidwood, Susquehanna, Summer, Prairie Island, Columbia, Seabrook, Brunswick, Surry, Limerick, North Anna, Turkey Point, River Bend, Vermont Yankee, Crystal River, Haddam Neck, Ginna, Diablo Canyon, Callaway, Vogtle, Waterford, Duane Arnold, Farley, Robinson, Clinton, South Texas, San Onofre, Cook, Comanche Peak, Yankee Rowe, Maine Yankee, Quad Cities, Humboldt Bay, La Crosse, Big Rock Point, Rancho Seco, Zion, Midland, Bellefonte, Fort Calhoun, FitzPatrick, McGuire, LaSalle, 05000000, Zimmer, Fort Saint Vrain, Shoreham, Satsop, Trojan, Atlantic Nuclear Power Plant, Skagit, Marble Hill |
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Category:NRC Information Notice
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Mclaughlin on NRC, Regarding NRC Information Notice 2006-13: Groundwater Contamination 2020-09-03 The following query condition could not be considered due to this wiki's restrictions on query size or depth: <code> [[:Beaver Valley]] OR [[:Millstone]] OR [[:Hatch]] OR [[:Monticello]] OR [[:Calvert Cliffs]] OR [[:Dresden]] OR [[:Davis Besse]] OR [[:Peach Bottom]] OR [[:Browns Ferry]] OR [[:Salem]] OR [[:Oconee]] OR [[:Mcguire]] OR [[:Nine Mile Point]] OR [[:Palisades]] OR [[:Palo Verde]] OR [[:Perry]] OR [[:Indian Point]] OR [[:Fermi]] OR [[:Kewaunee]] OR [[:Catawba]] OR [[:Harris]] OR [[:Wolf Creek]] OR [[:Saint Lucie]] OR [[:Point Beach]] OR [[:Oyster Creek]] OR [[:Watts Bar]] OR [[:Hope Creek]] OR [[:Grand Gulf]] OR [[:Cooper]] OR [[:Sequoyah]] OR [[:Byron]] OR [[:Pilgrim]] OR [[:Arkansas Nuclear]] OR [[:Three Mile Island]] OR [[:Braidwood]] OR [[:Susquehanna]] OR [[:Summer]] OR [[:Prairie Island]] OR [[:Columbia]] OR [[:Seabrook]] OR [[:Brunswick]] OR [[:Surry]] OR [[:Limerick]] OR [[:North Anna]] OR [[:Turkey Point]] OR [[:River Bend]] OR [[:Vermont Yankee]] OR [[:Crystal River]] OR [[:Haddam Neck]] OR [[:Ginna]] OR [[:Diablo Canyon]] OR [[:Callaway]] OR [[:Vogtle]] OR [[:Waterford]] OR [[:Duane Arnold]] OR [[:Farley]] OR [[:Robinson]] OR [[:Clinton]] OR [[:South Texas]] OR [[:San Onofre]] OR [[:Cook]] OR [[:Comanche Peak]] OR [[:Yankee Rowe]] OR [[:Maine Yankee]] OR [[:Quad Cities]] OR [[:Humboldt Bay]] OR [[:La Crosse]] OR [[:Big Rock Point]] OR [[:Rancho Seco]] OR [[:Zion]] OR [[:Midland]] OR [[:Bellefonte]] OR [[:Fort Calhoun]] OR [[:FitzPatrick]] OR [[:McGuire]] OR [[:LaSalle]] OR [[:05000000]] OR [[:Zimmer]] OR [[:Fort Saint Vrain]] OR [[:Shoreham]] OR [[:Satsop]] OR [[:Trojan]] OR [[:Atlantic Nuclear Power Plant]] OR [[:Skagit]] OR [[:Marble Hill]] </code>.
[Table view]The following query condition could not be considered due to this wiki's restrictions on query size or depth: <code> [[:Beaver Valley]] OR [[:Millstone]] OR [[:Hatch]] OR [[:Monticello]] OR [[:Calvert Cliffs]] OR [[:Dresden]] OR [[:Davis Besse]] OR [[:Peach Bottom]] OR [[:Browns Ferry]] OR [[:Salem]] OR [[:Oconee]] OR [[:Mcguire]] OR [[:Nine Mile Point]] OR [[:Palisades]] OR [[:Palo Verde]] OR [[:Perry]] OR [[:Indian Point]] OR [[:Fermi]] OR [[:Kewaunee]] OR [[:Catawba]] OR [[:Harris]] OR [[:Wolf Creek]] OR [[:Saint Lucie]] OR [[:Point Beach]] OR [[:Oyster Creek]] OR [[:Watts Bar]] OR [[:Hope Creek]] OR [[:Grand Gulf]] OR [[:Cooper]] OR [[:Sequoyah]] OR [[:Byron]] OR [[:Pilgrim]] OR [[:Arkansas Nuclear]] OR [[:Three Mile Island]] OR [[:Braidwood]] OR [[:Susquehanna]] OR [[:Summer]] OR [[:Prairie Island]] OR [[:Columbia]] OR [[:Seabrook]] OR [[:Brunswick]] OR [[:Surry]] OR [[:Limerick]] OR [[:North Anna]] OR [[:Turkey Point]] OR [[:River Bend]] OR [[:Vermont Yankee]] OR [[:Crystal River]] OR [[:Haddam Neck]] OR [[:Ginna]] OR [[:Diablo Canyon]] OR [[:Callaway]] OR [[:Vogtle]] OR [[:Waterford]] OR [[:Duane Arnold]] OR [[:Farley]] OR [[:Robinson]] OR [[:Clinton]] OR [[:South Texas]] OR [[:San Onofre]] OR [[:Cook]] OR [[:Comanche Peak]] OR [[:Yankee Rowe]] OR [[:Maine Yankee]] OR [[:Quad Cities]] OR [[:Humboldt Bay]] OR [[:La Crosse]] OR [[:Big Rock Point]] OR [[:Rancho Seco]] OR [[:Zion]] OR [[:Midland]] OR [[:Bellefonte]] OR [[:Fort Calhoun]] OR [[:FitzPatrick]] OR [[:McGuire]] OR [[:LaSalle]] OR [[:05000000]] OR [[:Zimmer]] OR [[:Fort Saint Vrain]] OR [[:Shoreham]] OR [[:Satsop]] OR [[:Trojan]] OR [[:Atlantic Nuclear Power Plant]] OR [[:Skagit]] OR [[:Marble Hill]] </code>. |
LIS ORIGINAL SSINS No.: 6835 IN 86-44 UNITED STATES NUCLEAR REGULATORY
COMMISSION
OFFICE OF INSPECTION
AND ENFORCEMENT
WASHINGTON, D.C. 20555 June 10, 1986 IE INFORMATION
NOTICE NO. 86-44: FAILURE TO FOLLOW PROCEDURES
WHEN WORKING IN HIGH RADIATION
AREAS
Addressees
All nuclear power reactor facilities
holding an operating
license (OL) or a construction
permit (CP) and research and test reactors.
Purpose
- This information
notice is provided to alert licensees
of the problem of recurring, unauthorized
entries by maintenance
workers into high radiation areas. A recent event is discussed
below, and a related event is summarized
in Attachment
1. Since the workers ignored and bypassed maintenance
procedures
that include radiological
controls established
to limit exposures
in high radiation
areas, it is fortuitous
that during these entries no personnel exposure limits were exceeded.It is expected that recipients
will review this notice for applicability
to their facilities'
work controls programs and consider actions, if appropriate, to preclude the occurrence
of a similar problem at their facilities.
Sugges-tions contained
in this information
notice do not constitute
NRC requirements
and, therefore, no specific action or written response is required.Past Related Correspondence:
INPO Significant
Event Report (SER) 50-85, "Uncontrolled
Personnel
Radiation Exposure," November 4, 1985 (discusses
two events).INPO Significant
Operating
Experience
Report (SOER) 85-3, "Excessive
Personnel Radiation
Exposures," April 30, 1985 (discusses
seven events).IE Information
Notice No. 84-19, "Two Events Involving
Unauthorized
Entries Into PWR Reactor Cavities," March 21, 1984.IE Information
Notice No. 84-59, "Deliberate
Circumventing
of Station Health Physics Procedures," August 6, 1984 (discusses
six events).8606040010
IN 86-44 June 10, 1986 Description
of Circumstances:
On January 8, 1986, at Turkey Point, an instrument
and controls (IC) technician
made an unaccompanied, unauthorized
entry into a high radiation
area to com-plete repairs on the traversing
incore probe (TIP) drive unit with an irradi-ated TIP withdrawn
into the work area. Earlier that same day, with a health physics (HP) technician
providing
job coverage, the IC technician
had made adjustments
to the TIP drive unit (dose rates only 5 to 25 mR/hr), which later enabled the technician
to successfully
withdraw the TIP into the accessible
TIP drive work area.During the unauthorized
entry, the IC technician
received 500 millirem whole body exposure during an approximately
5-minute stay time in a work area, which was later calculated
to be 6 R/hr in the general area. The radiation
level 1 foot away from the work area was 65-70 R/hr on contact with the tubing contain-ing the irradiated
TIP. The low-range
Geiger-Mueller (GM) portable survey instrument (scale of 0-1 R/hr) used by the IC technician
upon entering the high radiation
area initially
moved up the scale to 800 mR/hr and then reportedly
went rapidly down the scale to zero, when moved closer the the radiation source. The IC technician
failed to recognize
the malfunctioning
survey instrument
and stayed in the area to complete his maintenance
task. At these dose rates, it was fortuitous
that the technician
did not remain in the TIP area for any longer period.Subsequent
licensee and NRC regional review of the event revealed several key factors that contributed
to the incident.1. Failure To Follow Procedures
Numerous procedural
violations
occurred before and during the unauthorized
entry. These violations
included failure to notify HP personnel
before operating
the TIP, performing
craft work outside the scope of the author-ized plant work order (PWO), and making entry and working alone on the TIP system.2. Personnel
Shortcomings
The IC technician's
foreman failed to clearly define the TIP system problem and provide adequate instructions
on the PWO. The IC technician
failed to obey the local radiological
area warning, a posting that read "high radiation
area -keep out." Inadequate
training caused the IC technician
to fail to recognize
a malfunctioning
survey instrument (downscale
reading caused by GM detector tube continuous
discharge
response to intense radiation
levels), which he was using to help control his exposure.The NRC noted subsequent
to the event that, although not contributory
to this incident, governing
maintenance
procedures
for the TIP system did not require tagging out of other operable TIPs (to prevent inadvertent
withdrawal
into an occupied work area) with work in progress on a malfunctioning
TIP unit. For future TIP work, the licensee agreed to control movement of the irradiated
TIPs with equipment
tag out controls.
IN 86-44 June 10, 1986 Discussion:
The NRC continues
to note repeated occurrences
of unauthorized
entries into high radiation
areas (see Past Related Correspondence).
In most of the indi-vidual events discussed
in these documents
and the two events in this notice, failure of personnel
to adhere to existing work/control
procedures
or radiation work permits (RWP), or both, is a central cause of the exposure incidents.
Adherence
to work/surveillance
procedures
forms a basic framework
for providing effective, consistent
radiological
controls for work in high radiation
areas.Short of providing
direct, continuous
health physics coverage for each and every task, these procedures
serve as the formal mechanism
for initiating
necessary
communications
between various plant worker crafts groups and the health physics support group. This communication
results in appropriate
radiological
support (e.g., RWP issuance)
for the maintenance/surveillance
activities.
Bypassing
these procedures
and thus failing to comply with the radiological
precautions
in them seriously
weakens the health physics control program established
to protect the workers. It is the licensee's
responsibil- ity to ensure that these procedures
are adhered to.To emphasize
the importance
of workers properly performing
work activities
in high radiation
areas, appropriate
enforcement
action has been proposed for the Turkey Point event (proposed
$50,000 civil penalty).No specific action or written response is required by this information
notice.If you have any questions
about this matter, please contact the Regional Administrator
of the appropriate
regional office or this office.dwari o Jor , D irector Division of Emergency
Preparedness
and Engineering
Response Office of Inspection
and Enforcement
Technical
Contacts:
James E. Wigginton, IE (301) 492-4967 Roger L. Pedersen, IE (301) 492-9425 Attachments:
1. Related Exposure Event 2. List of Recently Issued IE Information
Notices
Attachment
1 IN 86-44 June 10, 1986 RELATED EVENT SUMMARY At the Cooper Nuclear Station on August 28, 1985, two IC technicians
performed maintenance (TIP alignment)
as required by a craft work procedure.
Contrary to the work procedure's
radiological-cautions
warnings, these workers failed to obtain a special RWP and entered the TIP drive enclosure
housing, ignoring the access posting, "Notify Health Physics Prior to Opening." The TIP maintenance
procedure
further warned that the drive unit's Gleason reel is spring loaded and the incore detector could be withdrawn
by the spring tension. It further warned that the withdrawn
incore detector probe could be highly radioactive.
Upon opening the unsurveyed
enclosure, they found the TIP had withdrawn
into the enclosure
and the detector had broken off. The technicians
immediately
exited the high radiation
and high airborne radioactivity
area. The indivi-duals each received approximately
200 mrem whole body exposure and airborne intakes of 44 and 90 MPC-hrs.As corrective
actions, the licensee (1) stressed to all station personnel
the importance
of properly following
radiological
controls and (2) revised the governing
maintenance
procedure
to require written documentation (signoff)notifying
HP before working on the TIP system.
Attachment
2 IN 86-44 June 10, 1986 LIST OF RECENTLY ISSUED IE INFORMATION
NOTICES Information
Date of Notice No. Subject Issue Issued to 86-43 Problems Sampling iodine With Silver Zeolite Of Airborne Radio-86-42 Improper Maintenance
Radiation
Monitoring
Of Systems 86-41 86-32 Sup. 1 86-40 86-39 86-38 Evaluation
Of Questionable
Exposure Readings Of Licensee Personnel
Dosimeters
Request For Collection
Of Licensee Radioactivity
Measurements
Attributed
to The Chernobyl
Nuclear Plant Accident Degraded Ability To Isolate The Reactor Coolant System From Low-Pressure
Coolant Systems in BWRS Failures Of RHR Pump Motors And Pump Internals Deficient
Operator Actions Following
Dual Function Valve Failures Degradation
Of Station Batteries Change In NRC Practice Regarding
Issuance Of Confirming
Letters To Principal
Contractors
6/10/86 6/9/86 6/9/86 6/6/86 6/5/86 5/20/86 5/20/86 5/16/86 5/16/86-All power reactor facilities
holding an OL or CP All power rector facilities
holding an OL or CP All byproduct material licensees All power reactor facilities
holding an OL or CP All power reactor facilities
holding an OL or CP All power reactor facilities
holding an OL or CP All power reactor facilities
holding an OL or CP All power reactor facilities
holding an OL or CP All power reactor facilities
holding an OL or CP 86-37 86-36 OL = Operating
License CP = Construction
Permit
|
---|
|
list | - Information Notice 1986-01, Failure of Main Feedwater Check Valves Causes Loss of Feedwater System Integrity and Water-Hammer Damage (6 January 1986)
- Information Notice 1986-02, Failure of Valve Operator Motor During Environmental Qualification Testing (6 January 1986)
- Information Notice 1986-03, Potential Deficiencies in Enviromental Qualification of Limitorque Motor Valve Operator Wiring (14 January 1986)
- Information Notice 1986-04, Transient Due to Loss of Power to Intergrated Control System at a Pressurized Water Reactor Designed by Babcock & Wilcox (31 January 1986)
- Information Notice 1986-05, Main Steam Safety Valve Test Failures and Ring Setting Adjustments (31 January 1986)
- Information Notice 1986-06, Failure of Lifting Rig Attachment, While Lifting Upper Guide Structure at St. Lucie Unit 1 (3 February 1986, Topic: Control of Heavy Loads)
- Information Notice 1986-06, Failure of Lifting Rig Attachment, while Lifting Upper Guide Structure at St. Lucie Unit 1 (3 February 1986)
- Information Notice 1986-07, Lack of Detailed Instruction & Inadequate Observance of Precautions During Maintenance & Testing of Diesel Generator Woodward Governors (3 February 1986)
- Information Notice 1986-08, Licensee Event Report (LER) Format Modification (3 February 1986)
- Information Notice 1986-09, Failure of Check & Stop Check Valves Subjected to Low Flow Conditions (3 February 1986)
- Information Notice 1986-10, Degradation of Reactor Coolant System Pressure Boundary Resulting From Boric Acid Corrosion. (5 January 1995, Topic: Boric Acid)
- Information Notice 1986-10, Feedwater Line Break (10 November 1988, Topic: Coatings, Anchor Darling)
- Information Notice 1986-10, Degradation of Reactor Coolant System Pressure Boundary Resulting from Boric Acid Corrosion. (5 January 1995, Topic: Boric Acid)
- Information Notice 1986-11, Anomalous Behavior of Recirculation Loop Flow in Jet Pump BWR Plants (31 December 1986)
- Information Notice 1986-13, Standby Liquid Control System Squib Valves Failure to Fire (21 February 1986, Topic: Squib)
- Information Notice 1986-13, Standby Liquid Control Squib Valves Failure to Fire (5 August 1986, Topic: Squib)
- Information Notice 1986-14, Overspeed Trips of AFW, HPCI & RCIC Turbines (26 August 1991, Topic: Fire Barrier)
- Information Notice 1986-14, Overspeed Trips of Afw, HPCI & RCIC Turbines (26 August 1991)
- Information Notice 1986-15, Loss of Offsite Power Caused by Problems in Fiber Optics Systems (10 March 1986, Topic: Squib)
- Information Notice 1986-16, Failures to Identify Containment Leakage Due to Inadequate Local Testing of BWR Vacuum Relief System Valves (11 March 1986, Topic: Squib)
- Information Notice 1986-17, Update of Failure of Automatic Sprinkler System Valves to Operate (24 March 1986, Topic: Squib)
- Information Notice 1986-18, NRC On-Scene Response During a Major Emergency (26 March 1986, Topic: Squib, Backfit)
- Information Notice 1986-19, Reactor Coolant Pump Shaft Failure at Crystal River (21 March 1986, Topic: Squib)
- Information Notice 1986-20, Low-Level Radioactive Waste Scaling Factors, 10 CFR Part 61 (28 March 1986, Topic: Squib)
- Information Notice 1986-21, Recognition of American Society of Mechanical Engineers Accreditation Program for N Stamp Holders (31 March 1986, Topic: Squib)
- Information Notice 1986-22, Underresponse of Radiation Survey Instrument to High Radiation Fields (31 March 1986, Topic: High Radiation Area, Squib)
- Information Notice 1986-23, Excessive Skin Exposures Due to Contamination with Hot Particles (9 April 1986)
- Information Notice 1986-23, Excessive Skin Exposures due to Contamination with Hot Particles (9 April 1986)
- Information Notice 1986-24, Respirator Users Notice: Increased Inspection Frequency for Certain Self-Contained Breathing Apparatus Air Cylinders (11 April 1986, Topic: Hydrostatic)
- Information Notice 1986-25, Traceability and Material Control of Material and Equipment, Particularly Fasteners (11 April 1986)
- Information Notice 1986-26, Potential Problems in Generators Manufactured by Electrical Products Incorporated (17 April 1986)
- Information Notice 1986-27, Access Control at Nuclear Facilities (21 April 1986, Topic: Contraband)
- Information Notice 1986-28, Telephone Numbers to the NRC Operations Center and Regional Offices (24 April 1986)
- Information Notice 1986-29, Effects of Changing Valve Moter-Operator Switch Settings (25 April 1986)
- Information Notice 1986-30, Design Limitations of Gaseous Effluent Monitoring Systems (29 April 1986)
- Information Notice 1986-31, Unauthorized Transfer and Loss of Control of Industrial Nuclear Gauges (14 July 1986)
- Information Notice 1986-32, Request for Collection of Licensee Radioactivity Measurements Attributed to Chernobyl Nuclear Plant Accident (2 May 1986, Topic: Chernobyl)
- Information Notice 1986-33, Information for Licensee Regarding the Chernobyl Nuclear Plant Accident (6 May 1986, Topic: Chernobyl)
- Information Notice 1986-34, Improper Assembly, Material Selection, & Test of Valves & Their Actuators (13 May 1986)
- Information Notice 1986-34, Improper Assembly, Material Selection, & Test of Valves & their Actuators (13 May 1986)
- Information Notice 1986-35, Fire in Compressible Material at Dresden Unit 3 (15 May 1986, Topic: Chernobyl)
- Information Notice 1986-36, Change in NRC Practice Regarding Issuance of Confirming Letters to Principal Contractors (16 May 1986, Topic: Chernobyl)
- Information Notice 1986-37, Degradation of Station Batteries (16 May 1986, Topic: Chernobyl)
- Information Notice 1986-38, Deficient Operator Actions Following Dual Function Valve Failures (20 May 1986, Topic: Chernobyl)
- Information Notice 1986-39, Failures of RHR Pump Motors and Pump Internals (20 May 1986, Topic: Chernobyl)
- Information Notice 1986-40, Degraded Ability to Isolate the Reactor Coolant System from Low-Pressure Coolant Systems in Bwrs (5 June 1986, Topic: Chernobyl)
- Information Notice 1986-40, Degraded Ability to Isolate the Reactor Coolant System from Low-Pressure Coolant Systems in BWRs (5 June 1986, Topic: Chernobyl)
- Information Notice 1986-41, Evaluation of Questionable Exposure Readings of Licensee Personnel Dosimeters (9 June 1986, Topic: Chernobyl)
- Information Notice 1986-42, Improper Maintenance of Radiation Monitoring Systems (9 June 1986, Topic: Temporary Modification, Chernobyl)
- Information Notice 1986-43, Problems with Silver Zeolite Sampling of Airborne Radioiodine (10 June 1986, Topic: Chernobyl)
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