ML090700284: Difference between revisions

From kanterella
Jump to navigation Jump to search
(Created page by program invented by StriderTol)
 
(Created page by program invented by StriderTol)
 
(One intermediate revision by the same user not shown)
Line 14: Line 14:
| page count = 22
| page count = 22
| project =  
| project =  
| stage = RAI
| stage = Draft Other
}}
}}


=Text=
=Text=
{{#Wiki_filter:P r a i r i e I s l a n d N u c l e a r G e n e r a t i n g P l a n t N R C R e g i o n I I I R e g u l a t o r y C o n f e r e n c e R a d i o a c t i v e M a t e r i a l T r a n s p o r t a t i o n E v e n t M a r c h 1 7 , 2 0 0 9 2 A g e n d a*O p e n i n g R e m a r k s -M i k e W a d l e y*S e q u e n c e o f E v e n t s -S c o t t N o r t h a r d *C a u s e s a n d C o r r e c t i v e A c t i o n s -S c o t t N o r t h a r d*P u b l i c R a d i a t i o n S a f e t y S i g n i f i c a n c e -S c o t t N e l s o n*C o n c l u s i o n -M i k e W a d l e y*C l o s i n g R e m a r k s -D e n n i s K o e h l 3 O p e n i n g R e m a r k s*P r a i r i e I s l a n d t a k e s i t s o b l i g a t i o n t o p r o t e c t t h e h e a l t h a n d s a f e t y o f t h e p u b l i c v e r y s e r i o u s l y-W e a g r e e w i t h t h e p e r f o r m a n c e d e f i c i e n c y , a n d t h e t w o v i o l a t i o n s a s s o c i a t e d w i t h t h e r a d i o a c t i v e m a t e r i a l s h i p m e n t-C a u s e s a n d c o r r e c t i v e a c t i o n s-P u b l i c r a d i a t i o n s a f e t y s i g n i f i c a n c e 4 S e q u e n c e o f E v e n t s S c o t t N o r t h a r d , P l a n t M a n a g e r 5 S e q u e n c e o f E v e n t s*O c t o b e r 2 3 , 2 0 0 8 -F u e l s i p p i n g e q u i p m e n t r e m o v e d f r o m t h e s p e n t f u e l p o o l , d e c o n n e d , s u r v e y e d , a n d w r a p p e d (L i d w a s 1 2 0 m R/h r)*O c t o b e r 2 4 , 2 0 0 8 -F u e l s i p p i n g e q u i p m e n t w a s l o a d e d i n t o s h i p p i n g c o n t a i n e r , s u r v e y e d a n d p l a c e d o n t h e t r a i l e r (H i g h e s t d o s e r a t e 1 7 0 m R/h r o n t h e m i d d l e b o t t o m o f c o n t a i n e r) *O c t o b e r 2 5 , 2 0 0 8 -S h i p p i n g p e r s o n n e l p e r f o r m e d c h a r a c t e r i z a t i o n o f f u e l s i p p i n g c o n t a i n e r 6 S e q u e n c e o f E v e n t s*O c t o b e r 2 9 , 2 0 0 8 -R W S C p e r f o r m e d c o n f i r m a t o r y s u r v e y o f c o n t a i n e r d o s e r a t e s t o v e r i f y c o n t a c t d o s e r a t e s w e r e w i t h i n D O T l i m i t s*O c t o b e r 2 9 , 2 0 0 8 -S h i p m e n t l e f t P r a i r i e I s l a n d*O c t o b e r 3 0 , 2 0 0 8 -S h i p m e n t a r r i v e d a t t h e r e c e i v i n g f a c i l i t y i n P e n n s y l v a n i a*O c t o b e r 3 0 , 2 0 0 8 -R e c e i v i n g f a c i l i t y p e r s o n n e l p e r f o r m e d i n i t i a l r e c e i p t s u r v e y o f t h e v e h i c l e a n d c o n f i r m e d d o s e r a t e s w e r e w i t h i n D O T l i m i t s 7 S e q u e n c e o f E v e n t s*O c t o b e r 3 1 , 2 0 0 8 -S h i p p i n g c o n t a i n e r s u r v e y w a s p e r f o r m e d b y t h e R e c e i v i n g F a c i l i t y-P a c k a g e s u r v e y i n d i c a t e d D O T l i m i t s e x c e e d e d o n a s m a l l s p o t o n t h e m i d d l e b o t t o m o f c o n t a i n e r:*2 , 0 0 0 m R/h r T e l e t e c t o r G e i g e r-M u e l l e r (G M) d e t e c t o r*8 0 0 m R/h r R O-2 I o n C h a m b e r (I C) d e t e c t o r-S t a t e o f P e n n s y l v a n i a a n d P r a i r i e I s l a n d n o t i f i e d-R e g i o n I I I R P I n s p e c t o r n o t i f i e d-S u s p e n d e d a l l r a d i o a c t i v e s h i p m e n t s p e n d i n g i n v e s t i g a t i o n a n d c o r r e c t i v e a c t i o n s 8 S e q u e n c e o f E v e n t s*N o v e m b e r 3 , 2 0 0 8 -N S P M F l e e t R a d i a t i o n P r o t e c t i o n M a n a g e r a n d a n R P T e c h n i c i a n a r r i v e d a t f a c i l i t y -c o n f i r m e d r e a d i n g s a n d l o c a t e d a d i s c r e t e p a r t i c l e o n a c a b l e-M a x i m u m d o s e r a t e 1 6 3 0 m R/h r T e l e p o l e G M-S h i p p i n g c o n t a i n e r p l a c e d b a c k o n t r a i l e r-V e r i f i e d v e h i c l e l i m i t s w e r e n o t e x c e e d e d-R e a d i n g s m a t c h e d i n i t i a l t r a n s p o r t v e h i c l e s u r v e y a t P r a i r i e I s l a n d S u m m a r y o f R a d i a t i o n M e a s u r e m e n t s 9 7 m R/h r E D E r a t e G e n e r a t e d E f f e c t i v e D o s e E q u i v a l e n t (E D E) r a t e c a l c u l a t i o n (R I S 2 0 0 3-0 4)1 6 3 0 m R/h r (T e l e p o l e G M)P r a i r i e I s l a n d c o n f i r m a t o r y s u r v e y 2 0 0 0 m R/h r (T e l e t e c t o r G M)8 0 0 m R/h r (R O-2 I C)P e r f o r m e d s h i p p i n g p a c k a g e s u r v e y i n s t o r a g e a r e a A l l r e s u l t s i n c o m p l i a n c e w i t h D O T v e h i c l e l i m i t s P e r f o r m e d v e h i c l e r e c e i p t s u r v e y. P a c k a g e r e m o v e d f r o m t r a i l e r , s e t i n R M A  (n o p a c k a g e s u r v e y).1 5 0 m R/h r o n b o x (T e l e p o l e G M)R W S C p e r f o r m e d c o n f i r m a t o r y p a c k a g e s u r v e y a s w e l l a s v e h i c l e s u r v e y.1 7 0 m R/h r o n b o x (T e l e p o l e G M)P a c k a g e l o a d e d w i t h e q u i p m e n t , s u r v e y e d , p l a c e d o n f l a t b e d.1 2 0 m R/h r o n l i d (R O-2 I C)E q u i p m e n t S u r v e y P e r f o r m e d 1/2/2 0 0 9 1 1/3/2 0 0 8 1 0/3 1/2 0 0 8 1 0/3 0/2 0 0 8 1 0/2 9/2 0 0 8 1 0/2 4/2 0 0 8 1 0/2 3/2 0 0 8 P r a i r i e I s l a n d C a l c u l a t i o n M e a s u r e m e n t s a t W a l t z M i l l M e a s u r e m e n t s a t P r a i r i e I s l a n d A c t i v i t y 1 0 M i s s e d O p p o r t u n i t i e s*J o b P l a n n i n g m i s s e d k e y m e t h o d s/H U t o o l s*D i s c r e t e R a d i o a c t i v e P a r t i c l e n o t d e t e c t e d*4 9 C F R S u b p a r t H q u a l i f i c a t i o n s n o t v e r i f i e d*P a c k a g i n g d i d n o t f i x p a r t i c l e s i n p l a c e*R W S C d i d n o t i n s p e c t p a c k a g i n g i n s i d e b o x*D i f f e r e n c e s i n c o n t e n t v s. s u r f a c e r e a d i n g s n o t q u e s t i o n e d b y R W S C , a n d r e a d i n g s c l o s e t o D O T l i m i t d i d n o t r e q u i r e a d d i t i o n a l o v e r s i g h t 1 1 C a u s e s a n d C o r r e c t i v e A c t i o n s*P r a i r i e I s l a n d R a d i a t i o n P r o t e c t i o n p e r s o n n e l d i d n o t a p p l y h u m a n p e r f o r m a n c e f u n d a m e n t a l s i n j o b p l a n n i n g a n d a l l o w e d a n u n a c c e p t a b l e l e v e l o f t o l e r a n c e f o r r i s k -P r e J o b B r i e f s n o w r e q u i r e i d e n t i f i c a t i o n o f c r i t i c a l s t e p s a n d a p p l i c a t i o n o f H U t o o l s f o r e r r o r r e d u c t i o n-R i s k M a t r i x d e v e l o p e d t o g u i d e R P r e l a t e d a c t i v i t y d e c i s i o n-m a k i n g-S i t e w i d e f o c u s o n H u m a n P e r f o r m a n c e I m p r o v e m e n t P l a n s-D i a g n o s t i c A s s e s s m e n t u s e d i n s u p e r v i s o r c o a c h i n g t o a d d r e s s b e h a v i o r s 1 2 C a u s e s a n d C o r r e c t i v e A c t i o n s*P r a i r i e I s l a n d R a d i a t i o n P r o t e c t i o n m e t h o d s w e r e i n a d e q u a t e t o d e t e c t t h e p r e s e n c e o f d i s c r e t e p a r t i c l e c o n t a m i n a t i o n o n m a t e r i a l s -P r o c e d u r e s n o w r e q u i r e t h e u s e o f r a d i a t i o n s u r v e y i n s t r u m e n t s t h a t p r o v i d e f a s t e r r e s p o n s e w i t h a n a u d i b l e i n d i c a t i o n o f d i s c r e t e p a r t i c l e s-A l l P r a i r i e I s l a n d R P T e c h n i c i a n s h a v e r e c e i v e d a d d i t i o n a l t r a i n i n g i n t h e u s e o f t h e c o r r e c t s u r v e y i n s t r u m e n t s a n d r e l a t e d p r o c e d u r e s 1 3 C a u s e s a n d C o r r e c t i v e A c t i o n s*P r a i r i e I s l a n d R a d i a t i o n P r o t e c t i o n m e t h o d s w e r e i n a d e q u a t e t o s u c c e s s f u l l y p a c k a g e r a d i o a c t i v e m a t e r i a l s -P r a i r i e I s l a n d n o w r e q u i r e s c o n t e n t s t o b e t i g h t l y w r a p p e d t o p r e v e n t t h e m f r o m s h i f t i n g i n t r a n s i t-A l l R P T e c h n i c i a n s h a v e r e c e i v e d a d d i t i o n a l t r a i n i n g i n t h e s e n e w p a c k i n g m e t h o d s-R W S C m u s t d i r e c t l y o v e r s e e t h e p a c k a g i n g o f a l l m a t e r i a l s f o r h i g h r i s k s h i p m e n t s-A l l p e r s o n n e l i n v o l v e d w i t h p a c k a g i n g a n d s h i p p i n g m u s t h a v e 4 9 C F R S u b p a r t H q u a l i f i c a t i o n s v e r i f i e d-H i g h R i s k s h i p m e n t s r e q u i r e c l o s e d t r a n s p o r t t r a i l e r 1 4 C a u s e s a n d C o r r e c t i v e A c t i o n s*P r a i r i e I s l a n d m a n a g e m e n t e n g a g e m e n t i n s h i p p i n g r a d i o a c t i v e m a t e r i a l s w a s i n a d e q u a t e -R a d i a t i o n P r o t e c t i o n S u p e r v i s o r n o w r e q u i r e d t o a p p r o v e s h i p m e n t s e x c e e d 4 0% o f D O T l i m i t s-P a c k a g e s p o t e n t i a l l y c o n t a i n i n g d i s c r e t e r a d i o a c t i v e p a r t i c l e s r e q u i r e R P M a n a g e r a p p r o v a l-S h i p m e n t s e x c e e d i n g 8 0% o f D O T l i m i t s r e q u i r e P l a n t M a n a g e r a p p r o v a l 1 5 P u b l i c R a d i a t i o n S a f e t y S i g n i f i c a n c e S c o t t N e l s o n , F l e e t R a d i a t i o n P r o t e c t i o n M a n a g e r 1 6 P u b l i c R a d i a t i o n S a f e t y S i g n i f i c a n c e R a d i a t i o n M e a s u r e m e n t s t a k e n a t r e c e i v e r f a c i l i t y*O c t o b e r 3 1 , 2 0 0 8 -R e a d i n g s r e p o r t e d t o t h e S t a t e o f P e n n s y l v a n i a:*2 , 0 0 0 m R/h r T e l e t e c t o r G M d e t e c t o r*8 0 0 m R/h r R O-2 I o n C h a m b e r d e t e c t o r 1 7 G-M a n d I o n C h a m b e r T e c h n o l o g y F u n d a m e n t a l D i f f e r e n c e s G e i g e r-M u e l l e r *H i g h s e n s i t i v i t y*R u g g e d , l i g h t , a n d h a s a u d i b l e o u t p u t*B e s t t o d e t e r m i n e t h e p r e s e n c e o f a r a d i a t i o n f i e l d D o e s n o t m e a s u r e t r u e d o s e r a t e I o n C h a m b e r *S l o w e r r e s p o n s e*M o s t a c c u r a t e*U s e d f o r c o n f i r m a t o r y m e a s u r e m e n t s M e a s u r e s t r u e d o s e r a t e A d d i t i o n a l R e f e r e n c e s*N R C R e g u l a t o r y G u i d e 7.3 , "P r o c e d u r e s f o r P i c k i n g U p a n d R e c e i v i n g R a d i o a c t i v e M a t e r i a l"*C R C P D E-5 , "G e n e r i c P r o c e d u r e s f o r t h e I n s p e c t i o n o f L o w-l e v e l R a d i o a c t i v e W a s t e C o n v e y a n c e , P a c k a g i n g a n d F o r m"B o t h d o c u m e n t s d i r e c t r e s u r v e y w i t h m o r e a c c u r a t e i n s t r u m e n t s w h e n l i m i t s a r e e x c e e d e d 1 8 S a f e t y S i g n i f i c a n c e*W e c o n c l u d e d:-I o n c h a m b e r m e a s u r e m e n t w a s t h e m o s t a c c u r a t e a s s e s s m e n t o f d o s e r a t e o n t h e p a c k a g e -D o s e r a t e s w e r e l e s s t h a n f i v e t i m e s t h e l i m i t , w h i c h m e e t s t h e c r i t e r i a f o r a W h i t e f i n d i n g 1 9 2 0 C o n c l u s i o n M i k e W a d l e y , S i t e V i c e P r e s i d e n t 2 1 C o n c l u s i o n*O u r p e r f o r m a n c e l e a d i n g u p t o t h i s s h i p m e n t d i d n o t m e e t e x p e c t a t i o n s a n d r e p r e s e n t s a n e r o s i o n o f p u b l i c c o n f i d e n c e*W e a g r e e w i t h t h e p e r f o r m a n c e d e f i c i e n c y a n d t h e a s s o c i a t e d v i o l a t i o n s*I m m e d i a t e a g g r e s s i v e a c t i o n s w e r e t a k e n t o p r e v e n t a n y f u r t h e r v i o l a t i o n s*T h o r o u g h e v a l u a t i o n a n d c o m p r e h e n s i v e c o r r e c t i v e a c t i o n s w e r e i m p l e m e n t e d*I o n C h a m b e r i s t h e m o s t a c c u r a t e i n s t r u m e n t f o r a s s e s s i n g s i g n i f i c a n c e a n d r e s u l t s i n a W h i t e f i n d i n g 2 2 C l o s i n g R e m a r k s D e n n i s K o e h l , C h i e f N u c l e a r O f f i c e r}}
{{#Wiki_filter:DRAFT Prairie Island Nuclear Generating Plant NRC Region III Regulatory Conference Radioactive Material Transportation Event March 17, 2009
 
DRAFT Agenda
* Opening Remarks - Mike Wadley
* Sequence of Events - Scott Northard
* Causes and Corrective Actions - Scott Northard
* Public Radiation Safety Significance - Scott Nelson
* Conclusion - Mike Wadley
* Closing Remarks - Dennis Koehl 2
 
DRAFT Opening Remarks
* Prairie Island takes its obligation to protect the health and safety of the public very seriously
  - We agree with the performance deficiency, and the two violations associated with the radioactive material shipment
  - Causes and corrective actions
  - Public radiation safety significance 3
 
DRAFT Sequence of Events Scott Northard, Plant Manager 4
 
DRAFT Sequence of Events
* October 23, 2008 - Fuel sipping equipment removed from the spent fuel pool, deconned, surveyed, and wrapped (Lid was 120 mR/hr)
* October 24, 2008 - Fuel sipping equipment was loaded into shipping container, surveyed and placed on the trailer (Highest dose rate 170 mR/hr on the middle bottom of container)
* October 25, 2008 - Shipping personnel performed characterization of fuel sipping container 5
 
DRAFT Sequence of Events
* October 29, 2008 - RWSC performed confirmatory survey of container dose rates to verify contact dose rates were within DOT limits
* October 29, 2008 - Shipment left Prairie Island
* October 30, 2008 - Shipment arrived at the receiving facility in Pennsylvania
* October 30, 2008 - Receiving facility personnel performed initial receipt survey of the vehicle and confirmed dose rates were within DOT limits 6
 
DRAFT Sequence of Events
* October 31, 2008 - Shipping container survey was performed by the Receiving Facility
  - Package survey indicated DOT limits exceeded on a small spot on the middle bottom of container:
* 2,000 mR/hr Teletector Geiger-Mueller (GM) detector
* 800 mR/hr RO-2 Ion Chamber (IC) detector
  - State of Pennsylvania and Prairie Island notified
  - Region III RP Inspector notified
  - Suspended all radioactive shipments pending investigation and corrective actions 7
 
DRAFT Sequence of Events
* November 3, 2008 - NSPM Fleet Radiation Protection Manager and an RP Technician arrived at facility - confirmed readings and located a discrete particle on a cable
  - Maximum dose rate 1630 mR/hr Telepole GM
  - Shipping container placed back on trailer
  - Verified vehicle limits were not exceeded
  - Readings matched initial transport vehicle survey at Prairie Island 8
 
DRAFT Summary of Radiation Measurements Activity                        Measurements at Prairie Island              Measurements at Waltz Mill            Prairie Island Calculation 10/23/2008  10/24/2008        10/29/2008  10/30/2008      10/31/2008  11/3/2008    1/2/2009 Equipment Survey Performed      120 mR/hr on lid (RO-2 IC)
Package loaded with                        170 mR/hr equipment, surveyed, placed                on box on flatbed.                                (Telepole GM)
RWSC performed confirmatory                                  150 mR/hr package survey as well as                                    on box vehicle survey.                                               (Telepole GM)
Performed vehicle receipt                                                  All results in survey. Package removed from                                                compliance trailer, set in RMA (no package                                            with DOT survey).                                                                   vehicle limits Performed shipping package                                                                2000 mR/hr survey in storage area                                                                    (Teletector GM) 800 mR/hr (RO-2 IC)
Prairie Island confirmatory                                                                            1630 mR/hr survey                                                                                                  (Telepole GM)
Generated Effective Dose                                                                                          97 mR/hr Equivalent (EDE) rate                                                                                              EDE rate calculation (RIS 2003-04)
 
DRAFT Missed Opportunities
* Job Planning missed key methods/HU tools
* Discrete Radioactive Particle not detected
* 49 CFR Subpart H qualifications not verified
* Packaging did not fix particles in place
* RWSC did not inspect packaging inside box
* Differences in content vs. surface readings not questioned by RWSC, and readings close to DOT limit did not require additional oversight 10
 
DRAFT Causes and Corrective Actions
* Prairie Island Radiation Protection personnel did not apply human performance fundamentals in job planning and allowed an unacceptable level of tolerance for risk
  - PreJob Briefs now require identification of critical steps and application of HU tools for error reduction
  - Risk Matrix developed to guide RP related activity decision-making
  - Site wide focus on Human Performance Improvement Plans
  - Diagnostic Assessment used in supervisor coaching to address behaviors                                11
 
DRAFT Causes and Corrective Actions
* Prairie Island Radiation Protection methods were inadequate to detect the presence of discrete particle contamination on materials
  - Procedures now require the use of radiation survey instruments that provide faster response with an audible indication of discrete particles
  - All Prairie Island RP Technicians have received additional training in the use of the correct survey instruments and related procedures 12
 
DRAFT Causes and Corrective Actions
* Prairie Island Radiation Protection methods were inadequate to successfully package radioactive materials
  - Prairie Island now requires contents to be tightly wrapped to prevent them from shifting in transit
  - All RP Technicians have received additional training in these new packing methods
  - RWSC must directly oversee the packaging of all materials for high risk shipments
  - All personnel involved with packaging and shipping must have 49 CFR Subpart H qualifications verified
  - High Risk shipments require closed transport trailer 13
 
DRAFT Causes and Corrective Actions
* Prairie Island management engagement in shipping radioactive materials was inadequate
  - Radiation Protection Supervisor now required to approve shipments exceed 40% of DOT limits
  - Packages potentially containing discrete radioactive particles require RP Manager approval
  - Shipments exceeding 80% of DOT limits require Plant Manager approval 14
 
DRAFT Public Radiation Safety Significance Scott Nelson, Fleet Radiation Protection Manager 15
 
DRAFT Public Radiation Safety Significance Radiation Measurements taken at receiver facility
* October 31, 2008
  - Readings reported to the State of Pennsylvania:
* 2,000 mR/hr Teletector GM detector
* 800 mR/hr RO-2 Ion Chamber detector 16
 
DRAFT G-M and Ion Chamber Technology Fundamental Differences Geiger-Mueller                  Ion Chamber
* High sensitivity
* Slower response
* Rugged, light, and has
* Most accurate audible output
* Used for confirmatory
* Best to determine the measurements presence of a radiation field Does not measure true          Measures true dose rate dose rate 17
 
DRAFT Additional References
* NRC Regulatory Guide 7.3, Procedures for Picking Up and Receiving Radioactive Material
* CRCPD E-5, Generic Procedures for the Inspection of Low-level Radioactive Waste Conveyance, Packaging and Form Both documents direct resurvey with more accurate instruments when limits are exceeded 18
 
DRAFT Safety Significance
* We concluded:
  - Ion chamber measurement was the most accurate assessment of dose rate on the package
  - Dose rates were less than five times the limit, which meets the criteria for a White finding 19
 
DRAFT Conclusion Mike Wadley, Site Vice President 20
 
DRAFT Conclusion
* Our performance leading up to this shipment did not meet expectations and represents an erosion of public confidence
* We agree with the performance deficiency and the associated violations
* Immediate aggressive actions were taken to prevent any further violations
* Thorough evaluation and comprehensive corrective actions were implemented
* Ion Chamber is the most accurate instrument for assessing significance and results in a White finding                                      21
 
DRAFT Closing Remarks Dennis Koehl, Chief Nuclear Officer 22}}

Latest revision as of 09:17, 14 November 2019

EA-08-349 Presentation - Draft from Prairie Island Nuclear Plant to Riii NRC for Regulatory Conference to Be Held March 17, 2009
ML090700284
Person / Time
Site: Prairie Island  Xcel Energy icon.png
Issue date: 03/17/2009
From:
Xcel Energy
To:
NRC/RGN-III
References
EA-08-349
Download: ML090700284 (22)


Text

DRAFT Prairie Island Nuclear Generating Plant NRC Region III Regulatory Conference Radioactive Material Transportation Event March 17, 2009

DRAFT Agenda

  • Opening Remarks - Mike Wadley
  • Sequence of Events - Scott Northard
  • Causes and Corrective Actions - Scott Northard
  • Conclusion - Mike Wadley
  • Closing Remarks - Dennis Koehl 2

DRAFT Opening Remarks

  • Prairie Island takes its obligation to protect the health and safety of the public very seriously

- We agree with the performance deficiency, and the two violations associated with the radioactive material shipment

- Causes and corrective actions

- Public radiation safety significance 3

DRAFT Sequence of Events Scott Northard, Plant Manager 4

DRAFT Sequence of Events

  • October 23, 2008 - Fuel sipping equipment removed from the spent fuel pool, deconned, surveyed, and wrapped (Lid was 120 mR/hr)
  • October 24, 2008 - Fuel sipping equipment was loaded into shipping container, surveyed and placed on the trailer (Highest dose rate 170 mR/hr on the middle bottom of container)
  • October 25, 2008 - Shipping personnel performed characterization of fuel sipping container 5

DRAFT Sequence of Events

  • October 29, 2008 - RWSC performed confirmatory survey of container dose rates to verify contact dose rates were within DOT limits
  • October 29, 2008 - Shipment left Prairie Island
  • October 30, 2008 - Shipment arrived at the receiving facility in Pennsylvania
  • October 30, 2008 - Receiving facility personnel performed initial receipt survey of the vehicle and confirmed dose rates were within DOT limits 6

DRAFT Sequence of Events

  • October 31, 2008 - Shipping container survey was performed by the Receiving Facility

- Package survey indicated DOT limits exceeded on a small spot on the middle bottom of container:

  • 800 mR/hr RO-2 Ion Chamber (IC) detector

- State of Pennsylvania and Prairie Island notified

- Region III RP Inspector notified

- Suspended all radioactive shipments pending investigation and corrective actions 7

DRAFT Sequence of Events

  • November 3, 2008 - NSPM Fleet Radiation Protection Manager and an RP Technician arrived at facility - confirmed readings and located a discrete particle on a cable

- Maximum dose rate 1630 mR/hr Telepole GM

- Shipping container placed back on trailer

- Verified vehicle limits were not exceeded

- Readings matched initial transport vehicle survey at Prairie Island 8

DRAFT Summary of Radiation Measurements Activity Measurements at Prairie Island Measurements at Waltz Mill Prairie Island Calculation 10/23/2008 10/24/2008 10/29/2008 10/30/2008 10/31/2008 11/3/2008 1/2/2009 Equipment Survey Performed 120 mR/hr on lid (RO-2 IC)

Package loaded with 170 mR/hr equipment, surveyed, placed on box on flatbed. (Telepole GM)

RWSC performed confirmatory 150 mR/hr package survey as well as on box vehicle survey. (Telepole GM)

Performed vehicle receipt All results in survey. Package removed from compliance trailer, set in RMA (no package with DOT survey). vehicle limits Performed shipping package 2000 mR/hr survey in storage area (Teletector GM) 800 mR/hr (RO-2 IC)

Prairie Island confirmatory 1630 mR/hr survey (Telepole GM)

Generated Effective Dose 97 mR/hr Equivalent (EDE) rate EDE rate calculation (RIS 2003-04)

DRAFT Missed Opportunities

  • Job Planning missed key methods/HU tools
  • Discrete Radioactive Particle not detected
  • 49 CFR Subpart H qualifications not verified
  • Packaging did not fix particles in place
  • RWSC did not inspect packaging inside box
  • Differences in content vs. surface readings not questioned by RWSC, and readings close to DOT limit did not require additional oversight 10

DRAFT Causes and Corrective Actions

  • Prairie Island Radiation Protection personnel did not apply human performance fundamentals in job planning and allowed an unacceptable level of tolerance for risk

- PreJob Briefs now require identification of critical steps and application of HU tools for error reduction

- Risk Matrix developed to guide RP related activity decision-making

- Site wide focus on Human Performance Improvement Plans

- Diagnostic Assessment used in supervisor coaching to address behaviors 11

DRAFT Causes and Corrective Actions

  • Prairie Island Radiation Protection methods were inadequate to detect the presence of discrete particle contamination on materials

- Procedures now require the use of radiation survey instruments that provide faster response with an audible indication of discrete particles

- All Prairie Island RP Technicians have received additional training in the use of the correct survey instruments and related procedures 12

DRAFT Causes and Corrective Actions

  • Prairie Island Radiation Protection methods were inadequate to successfully package radioactive materials

- Prairie Island now requires contents to be tightly wrapped to prevent them from shifting in transit

- All RP Technicians have received additional training in these new packing methods

- RWSC must directly oversee the packaging of all materials for high risk shipments

- All personnel involved with packaging and shipping must have 49 CFR Subpart H qualifications verified

- High Risk shipments require closed transport trailer 13

DRAFT Causes and Corrective Actions

  • Prairie Island management engagement in shipping radioactive materials was inadequate

- Radiation Protection Supervisor now required to approve shipments exceed 40% of DOT limits

- Packages potentially containing discrete radioactive particles require RP Manager approval

- Shipments exceeding 80% of DOT limits require Plant Manager approval 14

DRAFT Public Radiation Safety Significance Scott Nelson, Fleet Radiation Protection Manager 15

DRAFT Public Radiation Safety Significance Radiation Measurements taken at receiver facility

  • October 31, 2008

- Readings reported to the State of Pennsylvania:

  • 2,000 mR/hr Teletector GM detector
  • 800 mR/hr RO-2 Ion Chamber detector 16

DRAFT G-M and Ion Chamber Technology Fundamental Differences Geiger-Mueller Ion Chamber

  • High sensitivity
  • Slower response
  • Rugged, light, and has
  • Most accurate audible output
  • Used for confirmatory
  • Best to determine the measurements presence of a radiation field Does not measure true Measures true dose rate dose rate 17

DRAFT Additional References

  • CRCPD E-5, Generic Procedures for the Inspection of Low-level Radioactive Waste Conveyance, Packaging and Form Both documents direct resurvey with more accurate instruments when limits are exceeded 18

DRAFT Safety Significance

  • We concluded:

- Ion chamber measurement was the most accurate assessment of dose rate on the package

- Dose rates were less than five times the limit, which meets the criteria for a White finding 19

DRAFT Conclusion Mike Wadley, Site Vice President 20

DRAFT Conclusion

  • Our performance leading up to this shipment did not meet expectations and represents an erosion of public confidence
  • We agree with the performance deficiency and the associated violations
  • Immediate aggressive actions were taken to prevent any further violations
  • Thorough evaluation and comprehensive corrective actions were implemented
  • Ion Chamber is the most accurate instrument for assessing significance and results in a White finding 21

DRAFT Closing Remarks Dennis Koehl, Chief Nuclear Officer 22