ML20244C235: Difference between revisions
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{{Adams | |||
| number = ML20244C235 | |||
| issue date = 06/05/1989 | |||
| title = Insp Rept 50-440/89-16 on 890502-0602.Violations Noted Re Inadequate Surveys & Failure to Use Dosimetry in High Radiation Area.Major Areas Inspected:Allegations of Possible Overexposure.Overexposure Probably Did Not Occur | |||
| author name = Greger L, Kunowski M, Schumacher M | |||
| author affiliation = NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) | |||
| addressee name = | |||
| addressee affiliation = | |||
| docket = 05000440 | |||
| license number = | |||
| contact person = | |||
| document report number = 50-440-89-16, NUDOCS 8906140171 | |||
| package number = ML20244C228 | |||
| document type = INSPECTION REPORT, NRC-GENERATED, INSPECTION REPORT, UTILITY, TEXT-INSPECTION & AUDIT & I&E CIRCULARS | |||
| page count = 11 | |||
}} | |||
See also: [[see also::IR 05000440/1989016]] | |||
=Text= | |||
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U. S. NUCLEAR REGULATORY COMMISSION | |||
l | |||
REGION III | |||
.. | |||
l Report No. 50-440/89016(DRSS) | |||
. | |||
' | |||
Docket No. 50-440 License No. NPF-58 | |||
Licensee: Cleveland Electric Illuminating Company | |||
Post Office Box 5000 | |||
l- Cleveland, OH 44101 | |||
l Facility Name: Perry Nuclear Power Plant, Unit 1 | |||
Inspection At: Perry Site, Perry, Ohio | |||
Inspection Conducted: Hay 2 through June 2, 1989 | |||
Inspectors: M. A. Kunowski M . M. k 8~ | |||
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LYdte | |||
R. J. Caniano $pY b [//@ | |||
Reviewed By: | |||
'- 7 27 M A | |||
M. Schumacher, Chief #***/h[. / | |||
Radiological Controls Date | |||
and Che stry Section | |||
N Gff'f6 | |||
Approved By: L. Ro/bertGreger,Chif | |||
Reactor Programs 9 ranch Date | |||
Inspection Summary | |||
Inspection on May 2 through June 2, 1989 (Report No. 50-440/89016(DRSS)) | |||
Areas Inspected: Special, announced inspection to review allegations of | |||
a possible overexposure. | |||
Results: The inspectors' review of this event indicated that an overexposure | |||
probably did not occur; however: a potential for one appears to have existed. | |||
The radiation field intensity was not known at the time of entry. Also, | |||
the worker exited the area without completing his work assignment because he | |||
noted an unexpected SRD reading. The inspectors identified several radiological | |||
control weaknesses attendant to the event, including inadequate surveys in | |||
support of an RWP and a lack of aggressiveness and curiosity by the radiation | |||
protection technicians covering the drywell during the incident. Four | |||
allegations related to the incident were unsubstantiated; two allegations | |||
were substantiated (Sections 2 and 3). Four apparent violations of regulatory | |||
requirements were identified, including (1) inadequate surveys, (2) failure to | |||
document a survey, (3) failure to follow radiological control procedures for | |||
installation of shielding and for initiating a radiological occurrence report, | |||
and (4) failure to use appropriate dosimetry in a high radiation area. | |||
(Sections 2 and 3). | |||
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DETAILS | |||
1 | |||
1. Persons Contacted 1 | |||
*R. R. Bowers, Corporate Health Physicist | |||
*W. E. Coleman, Manager, Operations Quality Section | |||
+G. R. Dunn, Lead Engineer, Licensing and Compliance Section, Perry | |||
Plant Technical Department (PPTD) 1 | |||
*M. W. Gmyrek, Manager, Perry Plant Operations Department j | |||
+*H. L. Hegrat, Operations Engineer, Licensing and Compliance Section | |||
J. V. Ivery, Superintendent, R. J. Frazier | |||
*S. F. Kensicki, Director, PPTD | |||
*R. A. Newkirk, Manager, Licensing and Compliance Section i | |||
R. W. Parsons, Superintendent, R. J. Frazier 1 | |||
C. Reiter, Health Physics Supervisor, PPTD { | |||
T. E. Shega, System Engineer, PPTD | |||
*L. L. VanDerHorst, Plant Health Physicist, PPTD | |||
+*F. C. Whittaker, Lead Health Physics Supervisor, PPTD | |||
*S. J. Wojton, Manager, Radiation Protection Section, PPTD | |||
The inspectors also contacted other licensee employees, including | |||
technicians, workmen, and supervisors. | |||
*G. F. O'Dwyer, NRC Resident Inspector | |||
* Denotes those present at the exit meeting on May 10, 1989. | |||
+ Denotes those present at the exit telephone meeting on June 5, 1989. | |||
2. Allegation Followup | |||
(Closed) Allegation (AMS No. RIII-89-A-0054) l | |||
l | |||
a. Allegation Concern No. 1: A worker may have been overexposed during | |||
a job. | |||
An allegation concerning a possible overexposure was received | |||
in the Region III office on April 10, 1989; subsequent telephone | |||
conversations with the alleger were held on April 27. May 11, and | |||
May 31, 1989. The alleger stated that on March 24, 1989, a worker | |||
may have been overexposed when he was allowed to work in an unexpectedly | |||
high radiation field near a hotspot that was later determined to be | |||
12 R/hr on contact. Several concerns were expressed by the alleger, | |||
namely, that the worker was blamed for the exposure, that the RPM | |||
may have been covering up the exposure, that the Radiation Work | |||
Permit (RWP) for the job was not properly written, that the hotspot | |||
in the pipe should have been shielded, and that the worker had not | |||
been issued proper dosimetry for the job. | |||
These allegations were reviewed by Region III inspectors during a | |||
special onsite inspection on May 2-3, and May 8-10, 1989 and in | |||
subsequent telephone discussions with licensee representatives 1 | |||
2 i | |||
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1 | |||
through June 2, 1989. The inspection consisted of record and | |||
procedure review, job site observations, and interviews of workers | |||
.and licensee technical _and management personnel. | |||
Discussion: On March 24,1989, at 6:45 p.m. , the worker, who is a | |||
pipefitter, and his foreman entered the drywell on RWP 890335 to | |||
provide support for inservice inspection (ISI) work. Attached | |||
to the RWP.were several survey maps for various-locations in the | |||
drywell, including the general areas in which the men had to go. | |||
' | |||
The men stated they notified the radiation protection technicians | |||
(RPTs) at-the drywell access control desk before entry, as required | |||
by.the RWP, and were told of the radiological conditions in the | |||
areas in which they had to work, as shown on the survey maps. | |||
The individuals then entered the drywell and first went to the | |||
reactor water cleanup (RWCU) system on the 583' elevation. After | |||
approximately 30 minutes, the men left this area and went to the | |||
630' elevation to scope another job, removal of pipe supports | |||
(snubbers and pipe clamps) on the low pressure coolant injection | |||
(LPCI) line. The supports are located about 2' upstream of a LPCI | |||
line check valve in an approximately 3.5' x 5' x 6' pit, adjacent | |||
to, but below, the 630' elevation walkway. This pit is normally | |||
not accessible from the walkway, being enclosed by jet shielding; | |||
however, some of the jet shielding had been removed on March 22, | |||
1989, allowing access to it. | |||
Within the pit, the foreman recorded some preliminary data and | |||
explained to the worker what had to be done for the job. The men | |||
left the area after approximately 15 minutes (at about 8:00 p.m.) | |||
and returned to the drywell exit. As they left the drywell, they | |||
told the RPTs that they had received approximately 30 mrem, an | |||
unexpected amount, on their SRDs during their short time at the LPCI | |||
job site. The RPTs attributed this exposure to the time the workers | |||
spent at the RWCU job, where the general area dose rates ranged from | |||
100-150 mrem / hour, and not the LPCI job,'where general area dose | |||
rates supposedly ranged from 5-18 mrem / hour, according to the posted | |||
survey, dated May 16, 1989, taken before the jet shielding was removed. | |||
No records were found which showed that a survey of the pit area was | |||
conducted after removal of the jet shielding on March 22 and the | |||
initial pit entry by the workers on March 24. | |||
The RPT who was named in the allegation stated that after the men | |||
left he surveyed the pit and identified a 2.5 R/ hour (contact) | |||
hotspot on the LPCI pipe about 3' downstream of the snubbers, and | |||
also measured general area dose rates of 80-100 mR/ hour. These | |||
general area levels were about a factor of ten higher than those | |||
measured during the survey of March 16, 1989, which was being used | |||
to allow entry under the RWP. However, the March 16, 1989, survey | |||
was done with the jet shielding in place and, therefore, did not | |||
properly characterize the radiological conditions in the pit. The | |||
licensee's use of an inappropriate survey to govern RWP entry is an | |||
apparent violation of 10 CFR 20.201(b), which requires the licensee | |||
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.to make surveys that are necessary and reasonable to evaluate the | |||
extent of radiation hazards that may be present | |||
(No. 440/89016-01a). | |||
In addition, the inspectors determined that the survey identifying | |||
the 2.5 R/ hour hotspot was not documented, an apparent violation of | |||
the 10 CFR 20.401(b), which requires the licensee to maintain records | |||
of surveys required by 10 CFR 20.201(b) (No. 440/89016-02). | |||
At 11:45 p.m., the foreman and the worker returned to the drywell, | |||
with a second worker. The RPT stated he informed them of the survey | |||
results including the hotspot. (However, the worker and the foreman | |||
stated to the inspectors that they were not informed of any hotspot. | |||
The foreman stated that he and the RPT went to the work area, where | |||
the RPT explained that he had surveyed the area earlier in the day | |||
and that dose rates along the bottom of the pipe were 80 mR/ hour | |||
and indicated that general area dose rates were lower. The worker | |||
stated that the survey results that were relayed to him were general | |||
area dose rates were 30-40 mR/ hour.) | |||
The worker stated he began the job, assisted by the second worker, | |||
who did not enter the pit, but stayed on the 630' walkway to get | |||
tools as needed. Meanwhile, the foreman, with the agreernent of | |||
the RPT, obtained lead shielding and gave it to the workers, who | |||
" hung" it on the pipe near the snubbers. However, it appears that | |||
, | |||
the lead shielding was not placed around the pipe elbow, the spot | |||
identified by the RPT as the hot spot,-but on a horizontal section | |||
of the pipe near the snubbers. | |||
They continued working until the first worker read his low-range | |||
SRD, and observed what he thought was movement of the SR0 hairline. | |||
(Both workers stated to the inspectors that the worker read the SRD | |||
l | |||
because of.his apprehension about the radiation hazards in the area | |||
I | |||
and not because of such instructions by the RPT.) The workers | |||
immediately left the area and went to the drywell exit where they | |||
informed the named RPT of the behavior of the SRD. The worker | |||
estimated that he had been in the pit for 35 to 40 minutes before he | |||
left. | |||
The RWP record shows 210 mR total dose based on the worker's | |||
low range SRD; the RPT stated that the worker's high-range SRD | |||
read 50 mR. The RPT also stated that he told the worker that the | |||
discrepancy may be due to a faulty low-range SRD. (It was later | |||
ascribed by health physics management to differences in location ,' | |||
of the two dosimeters with respect to the hotspot.) | |||
The RPT stated that sometime later he resurveyed the pit with a | |||
different meter and found that the intensity of the hotspot had | |||
increased to 3.5 R/ hour and the general area dose rates had | |||
increased to 300-400 mR/ hour. The technician then returned to the | |||
drywell exit and informed the workers of the survey results. (The ! | |||
workers claim that when the technician returned, he apologized to | |||
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f them saying, in effect, that the meter he used for the previous | |||
survey must have been defective, and that there was a hotspot in the | |||
elbow of the pipe and general area dose rates were 300-400 mR/ hour. | |||
The workers then left the drywell, at about 12:30 a.m. , on March 25, | |||
1989. | |||
Another foreman (the general foreman) stated to the inspectors | |||
that after hearing of the hotspot, he borrowed a Bicron Model | |||
Tech 50 G-M survey meter from the RPTs at the drywell control | |||
desk and surveyed the elbow. He stated that he measured 5 R/ hour | |||
on contact with the elbow (5 R/ hour is the highest value obtainable | |||
-with this model survey meter.) | |||
According to the technician, after he informed the workers of the | |||
survey results he informed his supervisor of the apparent change | |||
in the radiological conditions in the pit. Subsequently, no further | |||
entries were allowed, pending an ALARA review. The RPT documented | |||
his survey approximately 30 minutes later, at 1:00 a.m. There | |||
is no record of the survey by the general foreman. | |||
During his next shift (on Saturday night, March 25th), the RPT- | |||
stated that he again surveyed the work area in the pit and determined | |||
that the hotspot was now reading 12 R/ hour and the general area dose | |||
rate was 1 R/ hour. For this survey, the RPT climbed down into the | |||
pit, whereas, for the two previous surveys, he-did not enter the pit, | |||
but just reached in with his meter from the walkway. An inspection | |||
of the work area by an NRC inspector indicated that because of the | |||
narrow, partially obstructed opening to the area, and the position | |||
of the 12" LPCI pipe in the pit, an adequate survey of the work area | |||
could not have been made from the walkway with the type of survey | |||
meter uscd by the technician. Performing the two surveys of the | |||
pit frow the walkway is another instance of an apparent violation | |||
of 10 CFR 20.201(b), which requires the licensee to make surveys | |||
that are reasonable to evaluate the extent of radiation hazards | |||
that may be present (No. 440/89016-01b). | |||
On his next shift, (Saturday-Sunday, March 25-26), the worker | |||
discussed the incident with an HP supervisor who took the worker's | |||
TLD for processing, and began an investigation to determine if an | |||
overexposure had occurred. Later, the worker discussed the incident | |||
with the HP supervisor responsible for external dosimetry on | |||
nightshift. This supervisor apparently tried to allay some of the | |||
worker's concerns, and provided, at the worker's request, a | |||
preliminary dose estimate that ranged from 210 mrem to 7000 mrem. | |||
The 210 mrem value was the worker's recorded dose for the job | |||
according to the low-range SRD and the 7000 mrem value was a | |||
worst-case estimate assuming the worker was in contact with a | |||
3.5 R/ hour hotspot for the entire 2 hours he spent in the drywell. | |||
The supervisor then refined the estimate by assuming 20% of the time | |||
was spent in transit to and from the work area, and explained to | |||
the worker that even this simple assumption would change the upper | |||
estimate from 7 rem to 4.76 rem. (The supervisor stated in a memo | |||
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dated March 26, 1989, that he later realized that he miscalculated | |||
the value, noting that 80% of 7 rem is 5.6 rem, not 4.76 rem.) After | |||
discussing this estimate and general information on the effects of | |||
radiation, the supervisor and the worker then discussed other | |||
details of the job. | |||
During the remainder of the week, the plant HP staff.made a more | |||
formal evaluation of the potential doses to the worker and the | |||
foreman. The evaluation used personal dosimetry results, a detailed | |||
. survey of the work area, and times and distances obtained from a | |||
reenactment of the job in the dose reconstruction. The reenactment | |||
was performed in the pit using an HP supervisor of similar height | |||
as a surrogate for the worker. The reconstruction for the worker | |||
assumed: | |||
(1) The head 12 inches from the hotspot for 26.5 minutes in a field | |||
of 500 mR/hr; | |||
(2) The head 9 inches from the hotspot for 26.5 minutes in a field | |||
of 1000 mR/hr; and | |||
(3) The head 3 inches from the hotspot for two minutes in a field | |||
~ | |||
of 3500 mR/hr. | |||
(According to licensee representatives, distances referenced for the | |||
dose rates were measured from the pipe to the center of the detector | |||
which is located approximately 1 1/2 inches from the base of the | |||
survey meter.) | |||
The resulting dose estimate to the head of the worker was 780 mrem | |||
for his two entries into the pit. A similar but more detailed | |||
scenario was used to estimate 346 millirems for the foreman's | |||
entries (17 minutes) into the pit. The corporate health physicist | |||
made. independent dose estimates based on the worker's dosimeter | |||
readings and allowing for attenuation through the body but using the | |||
same dose rate-time scenario. He obtained 750 and 860 mrem for the | |||
worker's high and low range dosimeters, respectively, which are not | |||
significantly different from the 780 mrem estimated by the station | |||
staff. | |||
The reconstruction was necessitated by the absence of dosimetry on | |||
the portion of the total body (the head or top of the back) nearest | |||
the hotspot. The reconstruction for the foreman appears better | |||
because it was based on his detailed written description of his | |||
actions and assumes a short period in contact with the pipe. The | |||
L | |||
reconstruction for the worker assumed no contact time despite the | |||
worker's assertion that he leaned against the pipe (although not | |||
necessarily the hot spot). An NRC inspector who entered the pit | |||
, | |||
noted that it was neither difficult nor awkward to place his head | |||
l on the LPCI pipe. The worker told NRC representatives that he was | |||
j not sure of time or positions with reference to the hotspot. | |||
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While the licensee's dose estimate of 780 mrem for the worker may | |||
be a reasonably good estimate of his actual dose, there is an | |||
uncertainty associated with this estimate due to the worker's stated | |||
lack of specific recollection of his body movements in the pit. | |||
However, because the worker did not recall having his head in | |||
contact with the pipe for a significant length of time, it does not | |||
appear that even under conservatively assumed conditions, he could | |||
have received a dose in excess of regulatory limits. | |||
Finding: This allegation could not be substantiated. It appears, | |||
based on the results of this inspection, that no overexposure | |||
occurred although the worker's dose may have been underestimated | |||
by assuming that no time was spent in direct contact with the | |||
hotspot. However, a potential for an overexposure did exist and | |||
an overexposure may have occurred if the worker had not left the | |||
work area when he did and/or if the hotspot radiation levels had | |||
been higher. Two apparent violations of NRC requirements were | |||
identified. | |||
b. Allegation Concern No. 2: The RPM told the worker that the exposure | |||
was the worker's fault. | |||
Discussion: The RPM denied making a statement of this nature to the | |||
worker. The RPM stated to the inspectors that while discussing the | |||
incident with the worker and hearing comments from the worker | |||
concerning how many times he questioned the RPTs about the dose | |||
rates in the area that he (the RPM) did tell the worker that if he | |||
was not satisfied with the answers he was getting from the techs | |||
that he should have pursued the matter at a higher level, as allowed | |||
and encouraged by station policy. | |||
Findings: The RPM made a statement that could be interpreted as | |||
ascribing fault to the worker; however, the RPM denied that was the | |||
intention. The allegation was not substantiated. No violations of | |||
NRC requirements were identified. | |||
c. Allegation Concern No. 3: The alleger stated that he was concerned | |||
that the RPM may be covering up the alleged overexposure because the | |||
RPM would not allow the worker to see or copy any of the records | |||
pertaining to the incident, and because of the RPM's statement that | |||
he (the RPM) "never had anyone burned out at Perry" and that he | |||
would evaluate the dose and "it will probably be under 1000 mR." | |||
This concern was reinforced by the fact that another HP supervisor | |||
had earlier given him an exposure estimate of 4.78 rem (The | |||
licensee's memo of March 26, 1989 refers to this estimate as | |||
4.76 rem. See Allegation Ccncern No. 1.) | |||
Discussion: The RPM stated to the inspectors that the worker | |||
requested to review or receive copies of some records but that | |||
he declined because the evaluation was not yet complete. The RPM | |||
stated that the worker was told that copies could be requested after | |||
completion of the evaluation. On May 2, 1989, the RPM told the | |||
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inspectors that the evaluation had been completed but no request | |||
from the worker had been received. He further stated that he had | |||
no reason:to deny the worker's request and, in fact, had responded | |||
l | |||
to a similar request from the foreman for his records. He added | |||
l that such detailed records are not normally given to workers. | |||
,- | |||
The RPM told the inspectors that he did not remember making the | |||
' statement that he "never had anyone burned out at Perry," but stated | |||
-that he did tell the worker that it was not Perry's policy to " burn | |||
out" workers; but rather it was Perry's policy to minimize dose to | |||
the individual and to groups of workers, and to equally distribute | |||
dose as much as possible. He also stated that his forecast of under | |||
1000 mR was based on his knowledge of the tentative results of the | |||
evaluation then in progress, which was much more plausible than the | |||
crude.4.76 rem estimate made before detailed measurements were taken | |||
in the pit. | |||
Findings: The inspectors could not substantiate the allegation | |||
that the RPM was concealing information from the worker regarding | |||
the worker's exposure. The RPM acknowledged that records of the | |||
incomplete evaluation were not given to the worker but stated that | |||
the worker was told he could request a copy of the evaluation when | |||
completed. No violations of NRC requirements were identified. | |||
d. Allegation Concern No. 4: The Radiation Work Permit (RWP) for the | |||
job on which the alleged overexposure occurred was not properly | |||
written. | |||
Discussion: TheallegerstatedthathewastoldbytheALARA | |||
Coordinator (name unknown) that the HP department ' screwed up the | |||
' | |||
RWP." The inspectors interviewed the members of the ALARA staff, | |||
including the dayshift and nightshift ALARA Coordinators, and | |||
several ALARA Specialists. The nightshift ALARA Coordinator | |||
remembered being questioned by an individual unknown to him about | |||
the incident but stated that he did not remember making such a | |||
statement about the RWP to the individual, and probably would not | |||
have made such a statement. RWP No. 890335, written March 1, 1989, | |||
covered in-service inspection and support work which included snubber | |||
removal in the pit. The RWP covered such work, throughout the | |||
drywell. It specified that HP be notified before the start of work | |||
so that area conditions may be established and also required either | |||
HP coverage or a dose rate meter to enter a high radiation area | |||
(HRA). The entire drywell was posted as an HRA with control over | |||
entry exercised at the HP desk at its entrance where the RWP sign-in | |||
sheets are kept. In this case, area conditions were established not | |||
from a survey at the time of entry on March 24, but from the record | |||
of.a survey made on March 16, as noted in the discussion under | |||
Allegation Concern No. 1, this survey was inadequate because it did | |||
not accurately depict conditions in the pit at the time of entry. | |||
Finding: The RWP, although very generally written, was adequate to | |||
prevent this occurrence had it been followed; therefore the | |||
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allegation was unsubstantiated. However, overall radiological | |||
control was vitiated due to inadequate surveys to establish | |||
radiological conditions, as described under Allegation Concern | |||
No. 1. | |||
e. Allegation Concern No. 5: A pipe with a hotspot should have been | |||
shielded during the work in the area. | |||
Discuss.ig : _ Station practice is to shield or flush hotspots before | |||
allowing work to proceed and if not practical, then to use other | |||
means to limit worker exposure such as restricting staytime or using | |||
alarming dosimeters. The opportunity to use such controls before | |||
work in the pit began on March 24 was missed due to the inadequate | |||
survey previously discussed. Also, the controls were not imposed | |||
before worker reentry following discovery of the 2.5 R/hr hotspot. | |||
Shielding was hung by the workers after reentry, at about 11:45 p.m. | |||
i However, it was not hung in accordance with Perry Administrative | |||
Procedure PAP-0122, " Selection and Use of Temporary Shielding," | |||
which requires completion of a request form PPNP No. 6623 and | |||
an estimate by the ALARA Coordinator of the person-rem that would | |||
be incurred if the shielding were not installed. Failure to | |||
follow this procedure is an apparent violction of Technical | |||
Specification 6.11.1 which requires adherence to procedures for | |||
personnel radiation protection (Violation 440/89016-3a). | |||
Finding: This allegation is substantiated. Although licensee | |||
procedures were vague on this point, good ALARA practice would have | |||
dictated shielding the hotspot before work began in the pit; that | |||
it was not hung then is an apparent result of the inadequate survey. | |||
When it was hung, it was done so improperly. _0ne apparent violation | |||
was identified. | |||
f. Allegation Concern No. 6: Dosimetry should have been placed on the | |||
worker's head while working near the hotspot. | |||
Discussion: Based on discussions with the worker and the foreman, a | |||
reenactment of the job, and survey information, it is apparent that | |||
a steep dose gradient existed in the work area, and that the highest | |||
dose during the job would have been to the head and upper back, | |||
not the chest where the dosimetry was placed. The dosimeters | |||
near the chest would have been subject to shielding from the worker's | |||
body, whereas a dosimeter on the head or upper back would not. | |||
Therefore, the dose recorded by the dosimeter near or on the chest | |||
would be inaccurate. So too would the dose determined by | |||
back-calculation from the dosimeter because of uncertainties in | |||
position of the chest with respect to the source and because of | |||
the varying shielding effect as the worker moved around in the | |||
work area. 10 CFR 20.202(a)(3) requires each licensee to supply | |||
appropriate personnel monitoring equipment to each individual | |||
who enters a high radiation area. In apparent violation of this | |||
requirement, the licensee did not supply appropriate personnel | |||
9 | |||
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, . | |||
. | |||
- | |||
. | |||
l | |||
l | |||
l | |||
l monitoring equipment to the two workers who entered the pit, a high | |||
radiation area, in that dosimetry was not placed on the part of | |||
' | |||
the whole body subject to the highest dose (No. 440/89016-04). | |||
Findings: The allegation was substantiated. One apparent violation | |||
of NRC requirements was identified. | |||
3. Licensee Performance | |||
This event revealed weaknesses in the licensee's radiological controls; | |||
most notable was the failure to adequately survey to determine | |||
radiological conditions attendant upon entry to the work area. This was | |||
significant because the controlling RWP was generally written, leaving | |||
radiological details to be determined by site-specific surveys. An | |||
adequate survey taken at entry should have resulted in identification of | |||
elevated radiation levels, an ALARA review, better worker instructions, | |||
and issuance of proper dosimetry such that the incident would have been | |||
avoided. An inadequate survey tends to undermine the RWP system of | |||
controls. | |||
A related and perhaps more fundamental weakness was the apparent lack of | |||
curiosity by the radiation protection group covering the drywell work on | |||
March 24-25, 1989, when the exiting workers first expressed concern about | |||
their SRD readings and again after the 2.5 R/ hour hotspot was identified. | |||
Opportunities to avoid an incident were again lost due to lack of | |||
aggressive response by the radiation protection group. | |||
Lack of aggressiveness also appeared to be a weakness in the licensee's | |||
followup investigation of the event. Problems identified by the | |||
inspectors included the following. | |||
* The licensee did not begin an investigation of this event until | |||
the worker sought out an HP supervisor on the worker's next shift | |||
(Saturday-Sunday, March 25-26) with complaints concerning the | |||
event. The foreman was not interviewed until two days after the | |||
incident (on Monday, March 27,1989), when he alto sought out an | |||
HP supervisor. | |||
* The licensee's investigation was too narrowly focused and did not | |||
include other relevant documents such as the work order covering | |||
the worker and his foreman and the HP drywell logbook until their | |||
relevance was pointed out by the inspectors. Both of these records | |||
indicated that other workers involved in snubber related work had | |||
entered the same general area; however, subsequent licensee review | |||
of these entries indicated they were not in close proximity to the | |||
hotspot. | |||
* The licensee had in place two procedures for conducting and | |||
documenting a thorough review which had not been invoked at the | |||
time of the inspection. Perry Administrative Procedure, PAP-0124, | |||
" Radiological Occurrence Reporting," should have been implemented | |||
by initiation of a Radiological Occurrence Report (ROR) shortly | |||
10 | |||
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. | |||
t . | |||
. | |||
, | |||
after the event. This procedure (Section 5.1) defines a | |||
radiological occurrence as "an event which results in or could | |||
result in a violation of the intent of Perry radiological | |||
procedures, practices, or policies; or personnel radiation exposures i | |||
in excess of administrative guides and 10 CFR 20 limits," The I | |||
procedure also states (Section 3.4) " Individuals are responsible | |||
for reporting radiological occurrences in a timely manner." Contrary | |||
to this requirement, and thus in apparent violation of Technical | |||
Specification 6.11.1, no ROR was initiated for this incident | |||
although it violated the intent of Perry radiological procedures, | |||
practices, and policies on ALARA and external exposure control | |||
(No.440/89016-03b). | |||
An example of an apparent violation of NRC requirements was identified. | |||
4. Exit Interview | |||
An exit interview was conducted with licensee representatives (Section 1) | |||
on May 10, 1989, to discuss the tentative findings and possible | |||
enforcement options. The inspector stated that although the event may | |||
not have resulted in an overexposure, a significant potential did exist | |||
for one. The inspector also identified several apparent violations | |||
including inadequate evaluation, failure to document a survey, | |||
unauthorized shielding placement, and failure to initiate an ROR. The | |||
licensee stated that a condition report (which has a higher threshold than | |||
an ROR) was being initiated. The licensee did not identify any material | |||
reviewed by the inspectors as proprietary. | |||
A telephone conversation was held with the licensee representatives | |||
(denoted in Section 1) on June 5. 1989, to discuss the inspection | |||
findings including apparent violations. The following matters were | |||
specifically addressed: | |||
a. NRC determination that an overexposure apparently did not occur, | |||
but that there may have been a substantial potential for one, | |||
b. Other specific allegation findings. | |||
c. Apparent violations for inadequate surveys (Section 2.a), for failure | |||
to document a survey (Section 2.a), for installation of temporary | |||
shielding and for failure to initiate a radiological occurrence | |||
. | |||
report both contrary | |||
to use appropriate to procedure | |||
dosimetry (Sections | |||
in a high 2.e | |||
radiation and 3)(, and failureSection 2 | |||
area | |||
d. Weaknesses in radiological controls related to the incident and in | |||
the licensee's followup. | |||
e. Confirmed the receipt of the list of topics to be specifically | |||
addressed at the Enforcement Conference, and the time, dtte, and | |||
location of the Enforcement Conference. | |||
11 | |||
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}} |
Latest revision as of 05:31, 1 February 2022
ML20244C235 | |
Person / Time | |
---|---|
Site: | Perry |
Issue date: | 06/05/1989 |
From: | Greger L, Michael Kunowski, Schumacher M NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
To: | |
Shared Package | |
ML20244C228 | List: |
References | |
50-440-89-16, NUDOCS 8906140171 | |
Download: ML20244C235 (11) | |
See also: IR 05000440/1989016
Text
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U. S. NUCLEAR REGULATORY COMMISSION
l
REGION III
..
l Report No. 50-440/89016(DRSS)
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Docket No. 50-440 License No. NPF-58
Licensee: Cleveland Electric Illuminating Company
Post Office Box 5000
l- Cleveland, OH 44101
l Facility Name: Perry Nuclear Power Plant, Unit 1
Inspection At: Perry Site, Perry, Ohio
Inspection Conducted: Hay 2 through June 2, 1989
Inspectors: M. A. Kunowski M . M. k 8~
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R. J. Caniano $pY b [//@
Reviewed By:
'- 7 27 M A
M. Schumacher, Chief #***/h[. /
Radiological Controls Date
and Che stry Section
N Gff'f6
Approved By: L. Ro/bertGreger,Chif
Reactor Programs 9 ranch Date
Inspection Summary
Inspection on May 2 through June 2, 1989 (Report No. 50-440/89016(DRSS))
Areas Inspected: Special, announced inspection to review allegations of
a possible overexposure.
Results: The inspectors' review of this event indicated that an overexposure
probably did not occur; however: a potential for one appears to have existed.
The radiation field intensity was not known at the time of entry. Also,
the worker exited the area without completing his work assignment because he
noted an unexpected SRD reading. The inspectors identified several radiological
control weaknesses attendant to the event, including inadequate surveys in
support of an RWP and a lack of aggressiveness and curiosity by the radiation
protection technicians covering the drywell during the incident. Four
allegations related to the incident were unsubstantiated; two allegations
were substantiated (Sections 2 and 3). Four apparent violations of regulatory
requirements were identified, including (1) inadequate surveys, (2) failure to
document a survey, (3) failure to follow radiological control procedures for
installation of shielding and for initiating a radiological occurrence report,
and (4) failure to use appropriate dosimetry in a high radiation area.
(Sections 2 and 3).
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DETAILS
1
1. Persons Contacted 1
- R. R. Bowers, Corporate Health Physicist
- W. E. Coleman, Manager, Operations Quality Section
+G. R. Dunn, Lead Engineer, Licensing and Compliance Section, Perry
Plant Technical Department (PPTD) 1
- M. W. Gmyrek, Manager, Perry Plant Operations Department j
+*H. L. Hegrat, Operations Engineer, Licensing and Compliance Section
J. V. Ivery, Superintendent, R. J. Frazier
- S. F. Kensicki, Director, PPTD
- R. A. Newkirk, Manager, Licensing and Compliance Section i
R. W. Parsons, Superintendent, R. J. Frazier 1
C. Reiter, Health Physics Supervisor, PPTD {
T. E. Shega, System Engineer, PPTD
- L. L. VanDerHorst, Plant Health Physicist, PPTD
+*F. C. Whittaker, Lead Health Physics Supervisor, PPTD
- S. J. Wojton, Manager, Radiation Protection Section, PPTD
The inspectors also contacted other licensee employees, including
technicians, workmen, and supervisors.
- G. F. O'Dwyer, NRC Resident Inspector
- Denotes those present at the exit meeting on May 10, 1989.
+ Denotes those present at the exit telephone meeting on June 5, 1989.
2. Allegation Followup
(Closed) Allegation (AMS No. RIII-89-A-0054) l
l
a. Allegation Concern No. 1: A worker may have been overexposed during
a job.
An allegation concerning a possible overexposure was received
in the Region III office on April 10, 1989; subsequent telephone
conversations with the alleger were held on April 27. May 11, and
May 31, 1989. The alleger stated that on March 24, 1989, a worker
may have been overexposed when he was allowed to work in an unexpectedly
high radiation field near a hotspot that was later determined to be
12 R/hr on contact. Several concerns were expressed by the alleger,
namely, that the worker was blamed for the exposure, that the RPM
may have been covering up the exposure, that the Radiation Work
Permit (RWP) for the job was not properly written, that the hotspot
in the pipe should have been shielded, and that the worker had not
been issued proper dosimetry for the job.
These allegations were reviewed by Region III inspectors during a
special onsite inspection on May 2-3, and May 8-10, 1989 and in
subsequent telephone discussions with licensee representatives 1
2 i
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through June 2, 1989. The inspection consisted of record and
procedure review, job site observations, and interviews of workers
.and licensee technical _and management personnel.
Discussion: On March 24,1989, at 6:45 p.m. , the worker, who is a
pipefitter, and his foreman entered the drywell on RWP 890335 to
provide support for inservice inspection (ISI) work. Attached
to the RWP.were several survey maps for various-locations in the
drywell, including the general areas in which the men had to go.
'
The men stated they notified the radiation protection technicians
(RPTs) at-the drywell access control desk before entry, as required
by.the RWP, and were told of the radiological conditions in the
areas in which they had to work, as shown on the survey maps.
The individuals then entered the drywell and first went to the
reactor water cleanup (RWCU) system on the 583' elevation. After
approximately 30 minutes, the men left this area and went to the
630' elevation to scope another job, removal of pipe supports
(snubbers and pipe clamps) on the low pressure coolant injection
(LPCI) line. The supports are located about 2' upstream of a LPCI
line check valve in an approximately 3.5' x 5' x 6' pit, adjacent
to, but below, the 630' elevation walkway. This pit is normally
not accessible from the walkway, being enclosed by jet shielding;
however, some of the jet shielding had been removed on March 22,
1989, allowing access to it.
Within the pit, the foreman recorded some preliminary data and
explained to the worker what had to be done for the job. The men
left the area after approximately 15 minutes (at about 8:00 p.m.)
and returned to the drywell exit. As they left the drywell, they
told the RPTs that they had received approximately 30 mrem, an
unexpected amount, on their SRDs during their short time at the LPCI
job site. The RPTs attributed this exposure to the time the workers
spent at the RWCU job, where the general area dose rates ranged from
100-150 mrem / hour, and not the LPCI job,'where general area dose
rates supposedly ranged from 5-18 mrem / hour, according to the posted
survey, dated May 16, 1989, taken before the jet shielding was removed.
No records were found which showed that a survey of the pit area was
conducted after removal of the jet shielding on March 22 and the
initial pit entry by the workers on March 24.
The RPT who was named in the allegation stated that after the men
left he surveyed the pit and identified a 2.5 R/ hour (contact)
hotspot on the LPCI pipe about 3' downstream of the snubbers, and
also measured general area dose rates of 80-100 mR/ hour. These
general area levels were about a factor of ten higher than those
measured during the survey of March 16, 1989, which was being used
to allow entry under the RWP. However, the March 16, 1989, survey
was done with the jet shielding in place and, therefore, did not
properly characterize the radiological conditions in the pit. The
licensee's use of an inappropriate survey to govern RWP entry is an
apparent violation of 10 CFR 20.201(b), which requires the licensee
3
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.to make surveys that are necessary and reasonable to evaluate the
extent of radiation hazards that may be present
(No. 440/89016-01a).
In addition, the inspectors determined that the survey identifying
the 2.5 R/ hour hotspot was not documented, an apparent violation of
the 10 CFR 20.401(b), which requires the licensee to maintain records
of surveys required by 10 CFR 20.201(b) (No. 440/89016-02).
At 11:45 p.m., the foreman and the worker returned to the drywell,
with a second worker. The RPT stated he informed them of the survey
results including the hotspot. (However, the worker and the foreman
stated to the inspectors that they were not informed of any hotspot.
The foreman stated that he and the RPT went to the work area, where
the RPT explained that he had surveyed the area earlier in the day
and that dose rates along the bottom of the pipe were 80 mR/ hour
and indicated that general area dose rates were lower. The worker
stated that the survey results that were relayed to him were general
area dose rates were 30-40 mR/ hour.)
The worker stated he began the job, assisted by the second worker,
who did not enter the pit, but stayed on the 630' walkway to get
tools as needed. Meanwhile, the foreman, with the agreernent of
the RPT, obtained lead shielding and gave it to the workers, who
" hung" it on the pipe near the snubbers. However, it appears that
,
the lead shielding was not placed around the pipe elbow, the spot
identified by the RPT as the hot spot,-but on a horizontal section
of the pipe near the snubbers.
They continued working until the first worker read his low-range
SRD, and observed what he thought was movement of the SR0 hairline.
(Both workers stated to the inspectors that the worker read the SRD
l
because of.his apprehension about the radiation hazards in the area
I
and not because of such instructions by the RPT.) The workers
immediately left the area and went to the drywell exit where they
informed the named RPT of the behavior of the SRD. The worker
estimated that he had been in the pit for 35 to 40 minutes before he
left.
The RWP record shows 210 mR total dose based on the worker's
low range SRD; the RPT stated that the worker's high-range SRD
read 50 mR. The RPT also stated that he told the worker that the
discrepancy may be due to a faulty low-range SRD. (It was later
ascribed by health physics management to differences in location ,'
of the two dosimeters with respect to the hotspot.)
The RPT stated that sometime later he resurveyed the pit with a
different meter and found that the intensity of the hotspot had
increased to 3.5 R/ hour and the general area dose rates had
increased to 300-400 mR/ hour. The technician then returned to the
drywell exit and informed the workers of the survey results. (The !
workers claim that when the technician returned, he apologized to
4
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f them saying, in effect, that the meter he used for the previous
survey must have been defective, and that there was a hotspot in the
elbow of the pipe and general area dose rates were 300-400 mR/ hour.
The workers then left the drywell, at about 12:30 a.m. , on March 25,
1989.
Another foreman (the general foreman) stated to the inspectors
that after hearing of the hotspot, he borrowed a Bicron Model
Tech 50 G-M survey meter from the RPTs at the drywell control
desk and surveyed the elbow. He stated that he measured 5 R/ hour
on contact with the elbow (5 R/ hour is the highest value obtainable
-with this model survey meter.)
According to the technician, after he informed the workers of the
survey results he informed his supervisor of the apparent change
in the radiological conditions in the pit. Subsequently, no further
entries were allowed, pending an ALARA review. The RPT documented
his survey approximately 30 minutes later, at 1:00 a.m. There
is no record of the survey by the general foreman.
During his next shift (on Saturday night, March 25th), the RPT-
stated that he again surveyed the work area in the pit and determined
that the hotspot was now reading 12 R/ hour and the general area dose
rate was 1 R/ hour. For this survey, the RPT climbed down into the
pit, whereas, for the two previous surveys, he-did not enter the pit,
but just reached in with his meter from the walkway. An inspection
of the work area by an NRC inspector indicated that because of the
narrow, partially obstructed opening to the area, and the position
of the 12" LPCI pipe in the pit, an adequate survey of the work area
could not have been made from the walkway with the type of survey
meter uscd by the technician. Performing the two surveys of the
pit frow the walkway is another instance of an apparent violation
of 10 CFR 20.201(b), which requires the licensee to make surveys
that are reasonable to evaluate the extent of radiation hazards
that may be present (No. 440/89016-01b).
On his next shift, (Saturday-Sunday, March 25-26), the worker
discussed the incident with an HP supervisor who took the worker's
TLD for processing, and began an investigation to determine if an
overexposure had occurred. Later, the worker discussed the incident
with the HP supervisor responsible for external dosimetry on
nightshift. This supervisor apparently tried to allay some of the
worker's concerns, and provided, at the worker's request, a
preliminary dose estimate that ranged from 210 mrem to 7000 mrem.
The 210 mrem value was the worker's recorded dose for the job
according to the low-range SRD and the 7000 mrem value was a
worst-case estimate assuming the worker was in contact with a
3.5 R/ hour hotspot for the entire 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> he spent in the drywell.
The supervisor then refined the estimate by assuming 20% of the time
was spent in transit to and from the work area, and explained to
the worker that even this simple assumption would change the upper
estimate from 7 rem to 4.76 rem. (The supervisor stated in a memo
5
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dated March 26, 1989, that he later realized that he miscalculated
the value, noting that 80% of 7 rem is 5.6 rem, not 4.76 rem.) After
discussing this estimate and general information on the effects of
radiation, the supervisor and the worker then discussed other
details of the job.
During the remainder of the week, the plant HP staff.made a more
formal evaluation of the potential doses to the worker and the
foreman. The evaluation used personal dosimetry results, a detailed
. survey of the work area, and times and distances obtained from a
reenactment of the job in the dose reconstruction. The reenactment
was performed in the pit using an HP supervisor of similar height
as a surrogate for the worker. The reconstruction for the worker
assumed:
(1) The head 12 inches from the hotspot for 26.5 minutes in a field
of 500 mR/hr;
(2) The head 9 inches from the hotspot for 26.5 minutes in a field
of 1000 mR/hr; and
(3) The head 3 inches from the hotspot for two minutes in a field
~
of 3500 mR/hr.
(According to licensee representatives, distances referenced for the
dose rates were measured from the pipe to the center of the detector
which is located approximately 1 1/2 inches from the base of the
survey meter.)
The resulting dose estimate to the head of the worker was 780 mrem
for his two entries into the pit. A similar but more detailed
scenario was used to estimate 346 millirems for the foreman's
entries (17 minutes) into the pit. The corporate health physicist
made. independent dose estimates based on the worker's dosimeter
readings and allowing for attenuation through the body but using the
same dose rate-time scenario. He obtained 750 and 860 mrem for the
worker's high and low range dosimeters, respectively, which are not
significantly different from the 780 mrem estimated by the station
staff.
The reconstruction was necessitated by the absence of dosimetry on
the portion of the total body (the head or top of the back) nearest
the hotspot. The reconstruction for the foreman appears better
because it was based on his detailed written description of his
actions and assumes a short period in contact with the pipe. The
L
reconstruction for the worker assumed no contact time despite the
worker's assertion that he leaned against the pipe (although not
necessarily the hot spot). An NRC inspector who entered the pit
,
noted that it was neither difficult nor awkward to place his head
l on the LPCI pipe. The worker told NRC representatives that he was
j not sure of time or positions with reference to the hotspot.
6
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.
While the licensee's dose estimate of 780 mrem for the worker may
be a reasonably good estimate of his actual dose, there is an
uncertainty associated with this estimate due to the worker's stated
lack of specific recollection of his body movements in the pit.
However, because the worker did not recall having his head in
contact with the pipe for a significant length of time, it does not
appear that even under conservatively assumed conditions, he could
have received a dose in excess of regulatory limits.
Finding: This allegation could not be substantiated. It appears,
based on the results of this inspection, that no overexposure
occurred although the worker's dose may have been underestimated
by assuming that no time was spent in direct contact with the
hotspot. However, a potential for an overexposure did exist and
an overexposure may have occurred if the worker had not left the
work area when he did and/or if the hotspot radiation levels had
been higher. Two apparent violations of NRC requirements were
identified.
b. Allegation Concern No. 2: The RPM told the worker that the exposure
was the worker's fault.
Discussion: The RPM denied making a statement of this nature to the
worker. The RPM stated to the inspectors that while discussing the
incident with the worker and hearing comments from the worker
concerning how many times he questioned the RPTs about the dose
rates in the area that he (the RPM) did tell the worker that if he
was not satisfied with the answers he was getting from the techs
that he should have pursued the matter at a higher level, as allowed
and encouraged by station policy.
Findings: The RPM made a statement that could be interpreted as
ascribing fault to the worker; however, the RPM denied that was the
intention. The allegation was not substantiated. No violations of
NRC requirements were identified.
c. Allegation Concern No. 3: The alleger stated that he was concerned
that the RPM may be covering up the alleged overexposure because the
RPM would not allow the worker to see or copy any of the records
pertaining to the incident, and because of the RPM's statement that
he (the RPM) "never had anyone burned out at Perry" and that he
would evaluate the dose and "it will probably be under 1000 mR."
This concern was reinforced by the fact that another HP supervisor
had earlier given him an exposure estimate of 4.78 rem (The
licensee's memo of March 26, 1989 refers to this estimate as
4.76 rem. See Allegation Ccncern No. 1.)
Discussion: The RPM stated to the inspectors that the worker
requested to review or receive copies of some records but that
he declined because the evaluation was not yet complete. The RPM
stated that the worker was told that copies could be requested after
completion of the evaluation. On May 2, 1989, the RPM told the
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,
inspectors that the evaluation had been completed but no request
from the worker had been received. He further stated that he had
no reason:to deny the worker's request and, in fact, had responded
l
to a similar request from the foreman for his records. He added
l that such detailed records are not normally given to workers.
,-
The RPM told the inspectors that he did not remember making the
' statement that he "never had anyone burned out at Perry," but stated
-that he did tell the worker that it was not Perry's policy to " burn
out" workers; but rather it was Perry's policy to minimize dose to
the individual and to groups of workers, and to equally distribute
dose as much as possible. He also stated that his forecast of under
1000 mR was based on his knowledge of the tentative results of the
evaluation then in progress, which was much more plausible than the
crude.4.76 rem estimate made before detailed measurements were taken
in the pit.
Findings: The inspectors could not substantiate the allegation
that the RPM was concealing information from the worker regarding
the worker's exposure. The RPM acknowledged that records of the
incomplete evaluation were not given to the worker but stated that
the worker was told he could request a copy of the evaluation when
completed. No violations of NRC requirements were identified.
d. Allegation Concern No. 4: The Radiation Work Permit (RWP) for the
job on which the alleged overexposure occurred was not properly
written.
Discussion: TheallegerstatedthathewastoldbytheALARA
Coordinator (name unknown) that the HP department ' screwed up the
'
RWP." The inspectors interviewed the members of the ALARA staff,
including the dayshift and nightshift ALARA Coordinators, and
several ALARA Specialists. The nightshift ALARA Coordinator
remembered being questioned by an individual unknown to him about
the incident but stated that he did not remember making such a
statement about the RWP to the individual, and probably would not
have made such a statement. RWP No. 890335, written March 1, 1989,
covered in-service inspection and support work which included snubber
removal in the pit. The RWP covered such work, throughout the
drywell. It specified that HP be notified before the start of work
so that area conditions may be established and also required either
HP coverage or a dose rate meter to enter a high radiation area
(HRA). The entire drywell was posted as an HRA with control over
entry exercised at the HP desk at its entrance where the RWP sign-in
sheets are kept. In this case, area conditions were established not
from a survey at the time of entry on March 24, but from the record
of.a survey made on March 16, as noted in the discussion under
Allegation Concern No. 1, this survey was inadequate because it did
not accurately depict conditions in the pit at the time of entry.
Finding: The RWP, although very generally written, was adequate to
prevent this occurrence had it been followed; therefore the
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allegation was unsubstantiated. However, overall radiological
control was vitiated due to inadequate surveys to establish
radiological conditions, as described under Allegation Concern
No. 1.
e. Allegation Concern No. 5: A pipe with a hotspot should have been
shielded during the work in the area.
Discuss.ig : _ Station practice is to shield or flush hotspots before
allowing work to proceed and if not practical, then to use other
means to limit worker exposure such as restricting staytime or using
alarming dosimeters. The opportunity to use such controls before
work in the pit began on March 24 was missed due to the inadequate
survey previously discussed. Also, the controls were not imposed
before worker reentry following discovery of the 2.5 R/hr hotspot.
Shielding was hung by the workers after reentry, at about 11:45 p.m.
i However, it was not hung in accordance with Perry Administrative
Procedure PAP-0122, " Selection and Use of Temporary Shielding,"
which requires completion of a request form PPNP No. 6623 and
an estimate by the ALARA Coordinator of the person-rem that would
be incurred if the shielding were not installed. Failure to
follow this procedure is an apparent violction of Technical
Specification 6.11.1 which requires adherence to procedures for
personnel radiation protection (Violation 440/89016-3a).
Finding: This allegation is substantiated. Although licensee
procedures were vague on this point, good ALARA practice would have
dictated shielding the hotspot before work began in the pit; that
it was not hung then is an apparent result of the inadequate survey.
When it was hung, it was done so improperly. _0ne apparent violation
was identified.
f. Allegation Concern No. 6: Dosimetry should have been placed on the
worker's head while working near the hotspot.
Discussion: Based on discussions with the worker and the foreman, a
reenactment of the job, and survey information, it is apparent that
a steep dose gradient existed in the work area, and that the highest
dose during the job would have been to the head and upper back,
not the chest where the dosimetry was placed. The dosimeters
near the chest would have been subject to shielding from the worker's
body, whereas a dosimeter on the head or upper back would not.
Therefore, the dose recorded by the dosimeter near or on the chest
would be inaccurate. So too would the dose determined by
back-calculation from the dosimeter because of uncertainties in
position of the chest with respect to the source and because of
the varying shielding effect as the worker moved around in the
work area. 10 CFR 20.202(a)(3) requires each licensee to supply
appropriate personnel monitoring equipment to each individual
who enters a high radiation area. In apparent violation of this
requirement, the licensee did not supply appropriate personnel
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l monitoring equipment to the two workers who entered the pit, a high
radiation area, in that dosimetry was not placed on the part of
'
the whole body subject to the highest dose (No. 440/89016-04).
Findings: The allegation was substantiated. One apparent violation
of NRC requirements was identified.
3. Licensee Performance
This event revealed weaknesses in the licensee's radiological controls;
most notable was the failure to adequately survey to determine
radiological conditions attendant upon entry to the work area. This was
significant because the controlling RWP was generally written, leaving
radiological details to be determined by site-specific surveys. An
adequate survey taken at entry should have resulted in identification of
elevated radiation levels, an ALARA review, better worker instructions,
and issuance of proper dosimetry such that the incident would have been
avoided. An inadequate survey tends to undermine the RWP system of
controls.
A related and perhaps more fundamental weakness was the apparent lack of
curiosity by the radiation protection group covering the drywell work on
March 24-25, 1989, when the exiting workers first expressed concern about
their SRD readings and again after the 2.5 R/ hour hotspot was identified.
Opportunities to avoid an incident were again lost due to lack of
aggressive response by the radiation protection group.
Lack of aggressiveness also appeared to be a weakness in the licensee's
followup investigation of the event. Problems identified by the
inspectors included the following.
- The licensee did not begin an investigation of this event until
the worker sought out an HP supervisor on the worker's next shift
(Saturday-Sunday, March 25-26) with complaints concerning the
event. The foreman was not interviewed until two days after the
incident (on Monday, March 27,1989), when he alto sought out an
HP supervisor.
- The licensee's investigation was too narrowly focused and did not
include other relevant documents such as the work order covering
the worker and his foreman and the HP drywell logbook until their
relevance was pointed out by the inspectors. Both of these records
indicated that other workers involved in snubber related work had
entered the same general area; however, subsequent licensee review
of these entries indicated they were not in close proximity to the
hotspot.
- The licensee had in place two procedures for conducting and
documenting a thorough review which had not been invoked at the
time of the inspection. Perry Administrative Procedure, PAP-0124,
" Radiological Occurrence Reporting," should have been implemented
by initiation of a Radiological Occurrence Report (ROR) shortly
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after the event. This procedure (Section 5.1) defines a
radiological occurrence as "an event which results in or could
result in a violation of the intent of Perry radiological
procedures, practices, or policies; or personnel radiation exposures i
in excess of administrative guides and 10 CFR 20 limits," The I
procedure also states (Section 3.4) " Individuals are responsible
for reporting radiological occurrences in a timely manner." Contrary
to this requirement, and thus in apparent violation of Technical
Specification 6.11.1, no ROR was initiated for this incident
although it violated the intent of Perry radiological procedures,
practices, and policies on ALARA and external exposure control
(No.440/89016-03b).
An example of an apparent violation of NRC requirements was identified.
4. Exit Interview
An exit interview was conducted with licensee representatives (Section 1)
on May 10, 1989, to discuss the tentative findings and possible
enforcement options. The inspector stated that although the event may
not have resulted in an overexposure, a significant potential did exist
for one. The inspector also identified several apparent violations
including inadequate evaluation, failure to document a survey,
unauthorized shielding placement, and failure to initiate an ROR. The
licensee stated that a condition report (which has a higher threshold than
an ROR) was being initiated. The licensee did not identify any material
reviewed by the inspectors as proprietary.
A telephone conversation was held with the licensee representatives
(denoted in Section 1) on June 5. 1989, to discuss the inspection
findings including apparent violations. The following matters were
specifically addressed:
a. NRC determination that an overexposure apparently did not occur,
but that there may have been a substantial potential for one,
b. Other specific allegation findings.
c. Apparent violations for inadequate surveys (Section 2.a), for failure
to document a survey (Section 2.a), for installation of temporary
shielding and for failure to initiate a radiological occurrence
.
report both contrary
to use appropriate to procedure
dosimetry (Sections
in a high 2.e
radiation and 3)(, and failureSection 2
area
d. Weaknesses in radiological controls related to the incident and in
the licensee's followup.
e. Confirmed the receipt of the list of topics to be specifically
addressed at the Enforcement Conference, and the time, dtte, and
location of the Enforcement Conference.
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