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| {{#Wiki_filter:LIS ORIGINAL SSINS No.: 6835 IN 86-44 UNITED STATES NUCLEAR REGULATORY | | {{#Wiki_filter:LIS ORIGINAL SSINS No.: 6835 IN 86-44 UNITED STATES |
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| COMMISSION | | NUCLEAR REGULATORY COMMISSION |
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| OFFICE OF INSPECTION | | OFFICE OF INSPECTION AND ENFORCEMENT |
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| ===AND ENFORCEMENT===
| | WASHINGTON, D.C. 20555 June 10, 1986 IE INFORMATION NOTICE NO. 86-44: FAILURE TO FOLLOW PROCEDURES WHEN WORKING |
| WASHINGTON, D.C. 20555 June 10, 1986 IE INFORMATION | |
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| |
|
| NOTICE NO. 86-44: FAILURE TO FOLLOW PROCEDURES
| | IN HIGH RADIATION AREAS |
| | |
| WHEN WORKING IN HIGH RADIATION
| |
| | |
| AREAS | |
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| |
|
| ==Addressees== | | ==Addressees== |
| : | | : |
| All nuclear power reactor facilities | | All nuclear power reactor facilities holding an operating license (OL) or a |
| | |
| holding an operating | |
| | |
| license (OL) or a construction | |
|
| |
|
| permit (CP) and research and test reactors. | | construction permit (CP) and research and test reactors. |
|
| |
|
| ==Purpose== | | ==Purpose== |
| : This information | | : |
| | This information notice is provided to alert licensees of the problem of |
|
| |
|
| notice is provided to alert licensees
| | recurring, unauthorized entries by maintenance workers into high radiation |
|
| |
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| of the problem of recurring, unauthorized
| | areas. A recent event is discussed below, and a related event is summarized in |
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| |
|
| entries by maintenance
| | Attachment 1. Since the workers ignored and bypassed maintenance procedures |
|
| |
|
| workers into high radiation areas. A recent event is discussed
| | that include radiological controls established to limit exposures in high |
|
| |
|
| below, and a related event is summarized
| | radiation areas, it is fortuitous that during these entries no personnel |
|
| |
|
| in Attachment
| | exposure limits were exceeded. |
|
| |
|
| 1. Since the workers ignored and bypassed maintenance
| | It is expected that recipients will review this notice for applicability to |
|
| |
|
| procedures
| | 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 |
|
| |
|
| that include radiological
| | and, therefore, no specific action or written response is required. |
|
| |
|
| controls established
| | Past Related Correspondence: |
| | INPO Significant Event Report (SER) 50-85, "Uncontrolled Personnel Radiation |
|
| |
|
| to limit exposures
| | Exposure," November 4, 1985 (discusses two events). |
|
| |
|
| in high radiation
| | INPO Significant Operating Experience Report (SOER) 85-3, "Excessive Personnel |
|
| |
|
| areas, it is fortuitous
| | Radiation Exposures," April 30, 1985 (discusses seven events). |
|
| |
|
| that during these entries no personnel exposure limits were exceeded.It is expected that recipients
| | IE Information Notice No. 84-19, "Two Events Involving Unauthorized Entries |
|
| |
|
| will review this notice for applicability
| | Into PWR Reactor Cavities," March 21, 1984. |
|
| |
|
| to their facilities'
| | IE Information Notice No. 84-59, "Deliberate Circumventing of Station Health |
| work controls programs and consider actions, if appropriate, to preclude the occurrence
| |
|
| |
|
| of a similar problem at their facilities.
| | Physics Procedures," August 6, 1984 (discusses six events). |
|
| |
|
| Sugges-tions contained
| | 8606040010 |
|
| |
|
| in this information
| | IN 86-44 June 10, 1986 |
|
| |
|
| notice do not constitute
| | ==Description of Circumstances== |
| | | : |
| ===NRC requirements=== | | On January 8, 1986, at Turkey Point, an instrument and controls (IC)technician |
| 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
| | 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 |
|
| |
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| that the technician
| | physics (HP) technician providing job coverage, the IC technician had made |
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| |
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| did not remain in the TIP area for any longer period.Subsequent
| | adjustments to the TIP drive unit (dose rates only 5 to 25 mR/hr), which later |
|
| |
|
| licensee and NRC regional review of the event revealed several key factors that contributed
| | enabled the technician to successfully withdraw the TIP into the accessible TIP |
|
| |
|
| to the incident.1. Failure To Follow Procedures
| | drive work area. |
|
| |
|
| Numerous procedural
| | During the unauthorized entry, the IC technician received 500 millirem whole |
|
| |
|
| violations
| | body exposure during an approximately 5-minute stay time in a work area, which |
|
| |
|
| occurred before and during the unauthorized
| | 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 |
|
| |
|
| entry. These violations
| | instrument (scale of 0-1 R/hr) used by the IC technician upon entering the high |
|
| |
|
| included failure to notify HP personnel
| | radiation area initially moved up the scale to 800 mR/hr and then reportedly |
|
| |
|
| before operating
| | went rapidly down the scale to zero, when moved closer the the radiation |
|
| |
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| the TIP, performing | | source. The IC technician failed to recognize the malfunctioning survey |
|
| |
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| 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
| | instrument and stayed in the area to complete his maintenance task. At these |
|
| |
|
| ===Shortcomings===
| | dose rates, it was fortuitous that the technician did not remain in the TIP |
| The IC technician's
| |
|
| |
|
| foreman failed to clearly define the TIP system problem and provide adequate instructions
| | area for any longer period. |
|
| |
|
| on the PWO. The IC technician
| | Subsequent licensee and NRC regional review of the event revealed several key |
|
| |
|
| failed to obey the local radiological
| | factors that contributed to the incident. |
|
| |
|
| area warning, a posting that read "high radiation
| | 1. Failure To Follow Procedures |
|
| |
|
| area -keep out." Inadequate
| | Numerous procedural violations occurred before and during the unauthorized |
|
| |
|
| training caused the IC technician
| | entry. These violations included failure to notify HP personnel before |
|
| |
|
| to fail to recognize
| | 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 |
|
| |
|
| a malfunctioning
| | system. |
|
| |
|
| survey instrument (downscale
| | 2. Personnel Shortcomings |
|
| |
|
| reading caused by GM detector tube continuous
| | The IC technician's foreman failed to clearly define the TIP system problem |
|
| |
|
| discharge
| | and provide adequate instructions on the PWO. The IC technician failed to |
|
| |
|
| response to intense radiation
| | obey the local radiological area warning, a posting that read "high |
|
| |
|
| levels), which he was using to help control his exposure.The NRC noted subsequent
| | radiation area - keep out." Inadequate training caused the IC technician |
|
| |
|
| to the event that, although not contributory | | to fail to recognize a malfunctioning survey instrument (downscale reading |
|
| |
|
| to this incident, governing | | caused by GM detector tube continuous discharge response to intense |
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| |
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| maintenance
| | radiation levels), which he was using to help control his exposure. |
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| |
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| procedures
| | The NRC noted subsequent to the event that, although not contributory to this |
|
| |
|
| for the TIP system did not require tagging out of other operable TIPs (to prevent inadvertent | | incident, governing maintenance procedures for the TIP system did not require |
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| |
|
| withdrawal | | tagging out of other operable TIPs (to prevent inadvertent withdrawal into an |
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| |
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| into an occupied work area) with work in progress on a malfunctioning
| | occupied work area) with work in progress on a malfunctioning TIP unit. For |
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| |
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| TIP unit. For future TIP work, the licensee agreed to control movement of the irradiated
| | future TIP work, the licensee agreed to control movement of the irradiated TIPs |
|
| |
|
| TIPs with equipment
| | with equipment tag out controls. |
| | |
| tag out controls. | |
|
| |
|
| IN 86-44 June 10, 1986 Discussion: | | IN 86-44 June 10, 1986 Discussion: |
| The NRC continues | | The NRC continues to note repeated occurrences of unauthorized entries into |
| | |
| 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 | | 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 |
|
| |
|
| of workers properly performing | | work permits (RWP), or both, is a central cause of the exposure incidents. |
|
| |
|
| work activities | | Adherence to work/surveillance procedures forms a basic framework for providing |
|
| |
|
| in high radiation | | effective, consistent radiological controls for work in high radiation areas. |
|
| |
|
| areas, appropriate
| | Short of providing direct, continuous health physics coverage for each and |
|
| |
|
| enforcement
| | every task, these procedures serve as the formal mechanism for initiating |
|
| |
|
| action has been proposed for the Turkey Point event (proposed
| | necessary communications between various plant worker crafts groups and the |
|
| |
|
| $50,000 civil penalty).No specific action or written response is required by this information
| | health physics support group. This communication results in appropriate |
|
| |
|
| notice.If you have any questions
| | radiological support (e.g., RWP issuance) for the maintenance/surveillance |
|
| |
|
| about this matter, please contact the Regional Administrator
| | activities. Bypassing these procedures and thus failing to comply with the |
|
| |
|
| of the appropriate
| | radiological precautions in them seriously weakens the health physics control |
|
| |
|
| regional office or this office.dwari o Jor , D irector Division of Emergency
| | program established to protect the workers. It is the licensee's responsibil- ity to ensure that these procedures are adhered to. |
|
| |
|
| ===Preparedness===
| | To emphasize the importance of workers properly performing work activities in |
| and Engineering
| |
|
| |
|
| Response Office of Inspection
| | high radiation areas, appropriate enforcement action has been proposed for the |
|
| |
|
| and Enforcement
| | Turkey Point event (proposed $50,000 civil penalty). |
|
| |
|
| Technical
| | No specific action or written response is required by this information notice. |
|
| |
|
| Contacts:
| | If you have any questions about this matter, please contact the Regional |
| 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
| | Administrator of the appropriate regional office or this office. |
|
| |
|
| Attachment
| | dwario Jor D , irector |
|
| |
|
| 1 IN 86-44 June 10, 1986 RELATED EVENT SUMMARY At the Cooper Nuclear Station on August 28, 1985, two IC technicians
| | Division of Emergency Preparedness |
|
| |
|
| performed maintenance (TIP alignment)
| | and Engineering Response |
| as required by a craft work procedure.
| |
|
| |
|
| Contrary to the work procedure's
| | Office of Inspection and Enforcement |
|
| |
|
| radiological-cautions
| | Technical Contacts: James E. Wigginton, IE |
|
| |
|
| warnings, these workers failed to obtain a special RWP and entered the TIP drive enclosure
| | (301) 492-4967 Roger L. Pedersen, IE |
|
| |
|
| housing, ignoring the access posting, "Notify Health Physics Prior to Opening." The TIP maintenance
| | (301) 492-9425 Attachments: |
| | 1. Related Exposure Event |
|
| |
|
| procedure
| | 2. List of Recently Issued IE Information Notices |
|
| |
|
| further warned that the drive unit's Gleason reel is spring loaded and the incore detector could be withdrawn
| | Attachment 1 IN 86-44 June 10, 1986 RELATED EVENT SUMMARY |
|
| |
|
| by the spring tension. It further warned that the withdrawn
| | At the Cooper Nuclear Station on August 28, 1985, two IC technicians performed |
|
| |
|
| incore detector probe could be highly radioactive.
| | maintenance (TIP alignment) as required by a craft work procedure. Contrary to |
|
| |
|
| Upon opening the unsurveyed
| | the work procedure's radiological-cautions warnings, these workers failed to |
|
| |
|
| enclosure, they found the TIP had withdrawn | | obtain a special RWP and entered the TIP drive enclosure housing, ignoring the |
|
| |
|
| into the enclosure
| | access posting, "Notify Health Physics Prior to Opening." The TIP maintenance |
|
| |
|
| and the detector had broken off. The technicians
| | procedure further warned that the drive unit's Gleason reel is spring loaded |
|
| |
|
| immediately
| | and the incore detector could be withdrawn by the spring tension. It further |
|
| |
|
| exited the high radiation
| | warned that the withdrawn incore detector probe could be highly radioactive. |
|
| |
|
| and high airborne radioactivity
| | Upon opening the unsurveyed enclosure, they found the TIP had withdrawn into |
|
| |
|
| area. The indivi-duals each received approximately
| | the enclosure and the detector had broken off. The technicians immediately |
|
| |
|
| 200 mrem whole body exposure and airborne intakes of 44 and 90 MPC-hrs.As corrective | | exited the high radiation and high airborne radioactivity area. The indivi- duals each received approximately 200 mrem whole body exposure and airborne |
|
| |
|
| actions, the licensee (1) stressed to all station personnel
| | intakes of 44 and 90 MPC-hrs. |
|
| |
|
| the importance | | As corrective actions, the licensee (1) stressed to all station personnel the |
|
| |
|
| of properly following | | importance of properly following radiological controls and (2) revised the |
|
| |
|
| radiological
| | governing maintenance procedure to require written documentation (signoff) |
| | notifying HP before working on the TIP system. |
|
| |
|
| controls and (2) revised the governing
| | Attachment 2 IN 86-44 June 10, 1986 LIST OF RECENTLY ISSUED |
|
| |
|
| maintenance
| | IE INFORMATION NOTICES |
|
| |
|
| procedure
| | Information Date of |
|
| |
|
| to require written documentation (signoff)notifying | | Notice No. Subject Issue Issued to |
|
| |
|
| HP before working on the TIP system.
| | 86-43 Problems With Silver Zeolite 6/10/86 All power reactor |
|
| |
|
| Attachment
| | Sampling Of Airborne Radio- facilities holding |
|
| |
|
| 2 IN 86-44 June 10, 1986 LIST OF RECENTLY ISSUED IE INFORMATION
| | iodine an OL or CP |
|
| |
|
| NOTICES Information
| | 86-42 Improper Maintenance Of 6/9/86 All power rector |
|
| |
|
| 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 Systems facilities holding |
|
| |
|
| Radiation
| | an OL or CP |
|
| |
|
| Monitoring
| | 86-41 Evaluation Of Questionable 6/9/86 All byproduct |
|
| |
|
| Of Systems 86-41 86-32 Sup. 1 86-40 86-39 86-38 Evaluation | | Exposure Readings Of Licensee material licensees |
|
| |
|
| ===Of Questionable===
| | Personnel Dosimeters |
| Exposure Readings Of Licensee Personnel
| |
|
| |
|
| Dosimeters
| | 86-32 Request For Collection Of 6/6/86 All power reactor |
|
| |
|
| Request For Collection
| | Sup. 1 Licensee Radioactivity facilities holding |
|
| |
|
| ===Of Licensee Radioactivity===
| | Measurements Attributed to an OL or CP |
| Measurements | |
|
| |
|
| Attributed
| | The Chernobyl Nuclear Plant |
|
| |
|
| to The Chernobyl
| | Accident |
|
| |
|
| Nuclear Plant Accident Degraded Ability To Isolate The Reactor Coolant System From Low-Pressure
| | 86-40 Degraded Ability To Isolate 6/5/86 All power reactor |
|
| |
|
| Coolant Systems in BWRS Failures Of RHR Pump Motors And Pump Internals Deficient | | The Reactor Coolant System facilities holding |
|
| |
|
| Operator Actions Following
| | From Low-Pressure Coolant an OL or CP |
|
| |
|
| Dual Function Valve Failures Degradation
| | Systems in BWRS |
|
| |
|
| Of Station Batteries Change In NRC Practice Regarding | | 86-39 Failures Of RHR Pump Motors 5/20/86 All power reactor |
|
| |
|
| Issuance Of Confirming
| | And Pump Internals facilities holding |
|
| |
|
| Letters To Principal
| | an OL or CP |
|
| |
|
| Contractors
| | 86-38 Deficient Operator Actions 5/20/86 All power reactor |
|
| |
|
| 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
| | Following Dual Function Valve facilities holding |
|
| |
|
| holding an OL or CP All power rector facilities
| | Failures an OL or CP |
|
| |
|
| holding an OL or CP All byproduct material licensees All power reactor facilities
| | 86-37 Degradation Of Station 5/16/86 All power reactor |
|
| |
|
| holding an OL or CP All power reactor facilities | | Batteries facilities holding |
|
| |
|
| holding an OL or CP All power reactor facilities
| | an OL or CP |
|
| |
|
| holding an OL or CP All power reactor facilities
| | 86-36 Change In NRC Practice 5/16/86- All power reactor |
|
| |
|
| holding an OL or CP All power reactor facilities | | Regarding Issuance Of facilities holding |
|
| |
|
| holding an OL or CP All power reactor facilities
| | Confirming Letters To an OL or CP |
|
| |
|
| holding an OL or CP 86-37 86-36 OL = Operating
| | Principal Contractors |
|
| |
|
| License CP = Construction | | OL = Operating License |
|
| |
|
| Permit}} | | CP = Construction Permit}} |
|
| |
|
| {{Information notice-Nav}} | | {{Information notice-Nav}} |
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 |
---|
Issue date: |
06/10/1986 |
---|
From: |
Jordan E NRC/IE |
---|
To: |
|
---|
References |
---|
IN-86-044, NUDOCS 8606040010 |
Download: ML031250056 (5) |
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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.
dwario 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 With Silver Zeolite 6/10/86 All power reactor
Sampling Of Airborne Radio- facilities holding
iodine an OL or CP
86-42 Improper Maintenance Of 6/9/86 All power rector
Radiation Monitoring Systems facilities holding
an OL or CP
86-41 Evaluation Of Questionable 6/9/86 All byproduct
Exposure Readings Of Licensee material licensees
Personnel Dosimeters
86-32 Request For Collection Of 6/6/86 All power reactor
Sup. 1 Licensee Radioactivity facilities holding
Measurements Attributed to an OL or CP
The Chernobyl Nuclear Plant
Accident
86-40 Degraded Ability To Isolate 6/5/86 All power reactor
The Reactor Coolant System facilities holding
From Low-Pressure Coolant an OL or CP
Systems in BWRS
86-39 Failures Of RHR Pump Motors 5/20/86 All power reactor
And Pump Internals facilities holding
an OL or CP
86-38 Deficient Operator Actions 5/20/86 All power reactor
Following Dual Function Valve facilities holding
Failures an OL or CP
86-37 Degradation Of Station 5/16/86 All power reactor
Batteries facilities holding
an OL or CP
86-36 Change In NRC Practice 5/16/86- All power reactor
Regarding Issuance Of facilities holding
Confirming Letters To an OL or CP
Principal Contractors
OL = Operating License
CP = Construction Permit
|
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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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