ML20210K642

Discusses Insp Repts 50-317/97-02 & 50-318/97-02 on 970302- 0412 & 50-317/97-03 & 50-318/97-03 on 970413-0531 & Notice of Violations & Proposed Imposition of Civil Penalty in Amount of $176,000

ML20210K642
Person / Time
Site:	Calvert Cliffs
Issue date:	08/11/1997
From:	Miller H NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Cruse C BALTIMORE GAS & ELECTRIC CO.
Shared Package
ML20210K648	List: ML20210K642 ML20210K651
References
50-317-97-02, 50-317-97-03, 50-317-97-2, 50-317-97-3, 50-318-97-02, 50-318-97-03, 50-318-97-2, 50-318-97-3, EA-97-192, NUDOCS 9708200004
Download: ML20210K642 (6)

See also: IR 05000317/1997002

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[ NUCLEAR REOULATORY COMMISSION

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. August 11,1997  !

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EA 97192

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Mr. Charles H. Cruse

Vice President . Nuclear Energy t

Baltimore Gas and Electric Company (BGE)  !

Calvert Cliffs Nuclear Power Plant

16bs Calvert Cliffs Perkway

Lusby, Maryland 20067 4702

SUBJECT: NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES

- $176,000

(NRC Inspection Reports Nos. 50 317/97 02 & 50 318/97-02; ,

50 317/97 03 & 60 318/37 03)  ;

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Dear Mr. Cruse:

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This letter refers to the NRC inspection conducted at the Calvert Cliffs Nuclear Power Plant

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from March 2,1997 to April 12,1997 and on April 24,1997, the findings of which were

provided to you during inn exit meeting on May 7,1997. The inspection report was sent to

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you on May 29,1997. During the inspection, several apparent violations were identified,

including a number of violations related to the f allure to effectively control activities conducted

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by a contractor diver in the Unit 2 spent fuel pool. Other apparent violations, related to .

inadequate rediation protection controls, as well as inadequate fuel handling operations, were

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also identified. On June 12,1997, a Predecisional Enforcement Conference was conducted

with you and members of your staff to discuss the violaticns, their causes, and your corrective  !'

actions. During the conference, two examples of an additional apparent violation of

radiological protection program requirements were also discussed. Those additional apparent

violations, which were identified by your staff,were reviewed by the NRC during an inspection

conducted between April 13,1997 to May 31,1997, for which an exit meeting was held on

June 19,1997. That inspection report was sent to you on July 1,1997.

Based on the information developed during the inspections, and the information provided

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durbg the enforcement conference, thirteen violet'ons of NRC requirements are being cited

and are described in the enclosed Notice of Violation and Proposed imposition of Civil t

Penalties (Notice). The three moat significant violations relate to the failure to implement

appropriate radiological controls during the diving operations in the Unit 2 spent fuel pool,  ;

resulting in the potential for a diver to gain unauthorized or inadvertent access to very high

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radiation areas that could have resulted in significant radiological exposure to the individual, t

Specifically, due to insufficient controls, inadequate pre job planning and communication,

ineffective surveillance of the diver, and deficient supervisory oversight of the activity, the

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ind!vidual was inadvertently able to gain access to areas in which radiation levels could be .

encountated at 500 rods or more in an hour due to the proximity of spent fuel.

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The specific violations associated with the diving activity involve (1) f ailure to ensure that the

diver would not be able to gain unauthorized or inadvertent access to areas where radiation

levels could be 600 tads or more in an hour; (2) f ailure to provide adequate instructions to the

diver as to the nature and location of very high radiation fields and the authorized work tasks;

and (3) f ailure to perform adequate surveys during and af ter the diver entered an area of the

spent fuel pool that had not boon previously surveyed. .our radiological control staff,

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responsible for plannint; and mNitoring this activity, failed to provide control of this activity

sufficient to assure thei the dives would not be unexpectedly exposed to, or inadvertently

enter, very high radiatko fields within the spent fuel storage pool.

This event occurred during the fourth of five dives into the Unit 2 refueling cavity and spent

fuel pool in April 1997 to inspect and repair malfunctioning fuel transfer equipment. During

the fourth dive, the diver lef t the previously surveyed and approved dive location at the south

end of the Unit 2 spent fuel pool, and moved into an unapproved, unsurveyed area ln the north

end of the pool. in doing so, the diver entered areas exhibiting significantly higher radiation

fields, where he received an unplanned radiation exposure, and could have been occupationally

exposed in excess of regulatory limits.

The fundamental controls provided to ensure that the diver could not gain unauthorized or

inadvertent access to very high radiation fields were inadequate. Even though the diver was

equipped with a tether, the individual monitoring the tether did not question the excessive

amount of restraint fSat was let out as the diver traversed to the unsurveyed north end of the

pool. While the diver was provided with multiple personal dosimetry devices that were

remotely monitored by the radiation protection technicie7s, he was not continuously monitored

by a television camera, as he had been during previous dives. Instead, the radiation protection

personnel were expected to provide continuous coverage via a viewing glass placed on the

surface of the pool. However, such coverage was flawed in that bubbles from the divera

breathing air and to some degree, the refueling bridge, obscured direct observation. Also, the

individual responsible for maintaining direct visual contact, by your own admission at the

enforcement conference, became distracted from his responsibilities. As a result, the radiation

protection personnel failed to observe the diver move away from the approved location.

Further, when the dosimetry readouts indicated that the diver was being exposed to higher

than expected fields, rather than confirming his whereabouts, the diver was inappropriately

directed to reenter the area to locate the source of the radiation,

h addition, the prejob briefing with the diver and dive support personnel was ineffective in

that a late change in the scope of the work directly resulted in the diver's misunderstanding

of the work scope. Also, the radiation survey briefing at the job site did not identify to the

diver the radiological hazard associated with the fresh irradiated fuelin'the north end of the

pool in that the diver was provided with a survey map of the south end of the pool, which he

interpreted as representing the entire pool. Moreover, the diver was unaware that he was

restricted from performing any activities at the north end of the spent fuel pool since the area

was not surveyed.

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Baltimore Gas and Electric Company 3

Af ter the fourth dive was completed, but prior to processing the diver's dosimetry, a decision

was made to initiate a fifth dive, using another diver to complete the repair / inspection.

Without his dosimetry first being processed to determine the exposure obtained during the

fourth dive, the diver from the fourth dive was allowed to re enter the spent fuel storage pool

work area to support the other diver. Although he re entered the radiological controlled area

and worked in areas with low radiation dose rates, a comprehensive dose assessment had not

been performed to determine whether the unauthorized entry into the unsurveyed area resulted

in the diver receiving a dose in excess of the limits of 10 CFR Part 20. Preliminary calculations

performed by your staff, indicated that the diver's right extremity (right knuckles) may have

entered radiation fields of 155 to 310 rem /hr and the whole body (right arm) may have entered

radiation fields ranging from 45 to 90 rem /hr.

Although subsequent detailed dose assessments for the diver indicated that no apparent

radiation exposure in excess of NRC limits likely occurred, this was nonetheless a significant

event given the serious consequences that could result from the diver being in close proximity

to irradiated fuel. Weaknesses in the establishment and implementation of the type of

radiological controls necessary to assure safety in the vicinity of very high radiation areas

resulted in a substantici potential for an exposure in excess of regulatory limits at the f acility.

In summary, the NRC considers that the event resulted from a serious lack of attention toward

licensed responsibilities. The event involved a serious breakdown in controls that were to be

provided for the diving evolutions. Significant deficiencies in communications, coordination,

and management oversight and decision making, also existed. As a result, a substantial and

unnecessary occupational exposure nearly occurred. Therefore, the violations in Section I,

which involve a very significant regulatory concern, have been classified in the aggregate as

a Severity Leveill problem in accordance with Section IV of the " General Statement of Policy

and Procedure for NRC Enforcement Actions " (Enforcement Policy), NUREG 1600.

In accordance with the Enforcement Policy, a base civil penalty in the amount of $88,000 lo

considered for a Severity Level ll violation or problem. Also, since this is a Severity Level ll

problem, the NRC considered whether credit was warranted for / dent /// cat /on and Correct /ve

Act/on in accordance with the civil penalty assessment process in Section VI.B.2 of the

Enforcement Policy. Credit for identification is not warranted because there were several

missed opportunities during the dive to identify these problems, particularly when dosimetry

first alarmed, when the technician lost visual contact of the diver because of the bubbling, and

when the diver asked a technician for more line and was not questioned. Credit for corrective

actions is also not warranted because the immediate corrective actions after the fourth dive

were deficient in that another diver was allowed to enter the pool without having obtained a

thorough understanding of the cause of the earlier "near miss". Giv'en the potential for

substantial personnel exposures that could result from being in such close proximity to the

irradiated fuel, a root cause analysis should have been performed before commencing the fifth

dive, as you acknowledged at the enforcement conference. Additionally, even though you

took action to change your radiological controlled area dive operations and formalize your job

coverage standard into a radiation safety procedure, you did not adequately assess the full

scope and root causes of the breakdown that occurred. For example, you did not determine

the extent to which production pressure was a f actor in causing the event. Further, during

the enforcement conference, you did not appear to understand all potential contributors to the

event, such as the cause of the inattentiveness of the lodividual assigned to observe the diver.

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Baltimore Gas and Electric Company 4 ,

Therefore, to emphasize the seriousness of this event, and the importance of appropriate

management control and oversight of such activities, I have been authorized, after

consultation with the Director, Of fice of Enforcement, to issue the encloseJ Notice of Violation

and Proposed imposition of Civil Penalty (Notice)in the amount of $176,000 f or the violations

in Section 1.

The remaining violations being cited are described in Sections ll and 111 of the enclosed Notice

and are classified at Severity LevelIV. A number of these vlotations were identified by your

staff and while a civil penalty is not being proposed for these violations, they are indicative

of further programmatic weaknesses in radiological controls and protection, maintenance of

refueling equipment, and conduct of refueling activities.

Two other apparent violations listed in Inspr.9 tion Report 97 02, which you identified,

involving (1) the f ailure to verify that each exhaust fan maintains the spent fuel storage pool

at a measurable negative pressure relative to the outside atmosphere during system operation,

and (2) the refueling machine's main holst 3,000 pound overload limit being bypassed during

portions of fuelmovement within the reactor pressure vessel, are not being cited because they

meet the criterla in Section Vll.B.1 of the enforcement policy regarding the exercise of

discretion. Further, another apparent vlotation ininspection Report 97 02, involving drawings

not being used to prepare either the troubleshooting form or contingency plans during

assessment and repair of the stuck refueling transfer carriage,is being withdrawn because of

information you provided at the conference where it was stated that drawings were used in

a parallel assessment of the event.

You are required to respond to this letter and should folicw the instructions specified in the

enclosed Notice when preparing your response. The NRC will use your response, in part, to

determine whether further enforcement action is necessary to ensure compliance with

regulatory requirements,

in accordance with 10 CFR 2.700 of the NRC's " Rules of Practice," a copy of this letter,its

enclosure, and your response will be placed in the NRC Public Document Room (PDR).

Sincerely,

[ $6

Hubert J. Miller '

Regional Administrator

Docket Nos. 50 317, 50 318

License Nos. DPR 53, DPR 69

Enclosure: Notice of Violation and Propoced Imposition of Civil Penalties

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' Baltimore Oas and Electric Company 5 *

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cc w/ encl:

T. Pritchett, Director, Nuclear Regulatory Matters (CCNPP) ,

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4 R. McLean, Administrator, Nuclear Evaluations

J. Walter, Engineering Division, Public Service Commission of Maryland

K. Burger, Esquire, Maryland People's Counsel ,

R. Ochs, Maryland Safe Energy Coalition  !

State of Maryland (2)

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DIGJRIBUTION:

PUBLIC

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LCallan, EDO  !

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AThadani, DEDE

JLloberman, OE

HMiller, RI

FDavis, OGC

SCollins, NRR

RZimmerman, NRR

Enforcement Coordinators

Al, Ril, Rill, RIV

BBeecher, GPA/PA

GCaputo, 01

PLohaus, OSP i'

HBell, OlG

Dross, AEOD

TReis, OE

OE:EA (Also by E Mail)

NUDOCS

DScrencl, PAO RI

NSheehan, PAO RI

LTremper, OC

Nuclear Safety Information Center (NSIC)

NRC Resident inspector . Calvert Cliffs ,

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