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{{Adams | |||
| number = ML20215G320 | |||
| issue date = 06/15/1987 | |||
| title = Insp Repts 50-266/87-11 & 50-301/87-10 on 870428-0519, Violations Noted:Failure to Properly Train Employees Using Radioactive Source & Failure to Clearly Label Contents of Radioactive Matl in Container | |||
| author name = Greger L, Miller D, Paul R | |||
| author affiliation = NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) | |||
| addressee name = | |||
| addressee affiliation = | |||
| docket = 05000266, 05000301 | |||
| license number = | |||
| contact person = | |||
| document report number = 50-266-87-11, 50-301-87-10, IEIN-86-023, IEIN-86-23, NUDOCS 8706230213 | |||
| package number = ML20215G310 | |||
| document type = INSPECTION REPORT, NRC-GENERATED, INSPECTION REPORT, UTILITY, TEXT-INSPECTION & AUDIT & I&E CIRCULARS | |||
| page count = 16 | |||
}} | |||
See also: [[see also::IR 05000266/1987011]] | |||
=Text= | |||
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1 | |||
U. S. NUCLEAR REGULATORY COMMISSION | |||
REGION III | |||
Reports No. 50-266/87011(DRSS); 50-301/87010(DRSS) | |||
Docket Nos. 50-266; 50-301 Licenses No. DPR-24; No. DPR-27 | |||
. | |||
Licensee: Wisconsin Electric Power Company | |||
231 West Michigan | |||
Milwaukee, WI 53201 | |||
Facility Name: Point Beach Nuclear Plant (PBNP) | |||
Inspection At: PBNP; Units 1 and 2, Two Rivers, Wisconsin | |||
Inspection Conducted: April 28 through May 19, 1987 l | |||
Inspector: 6//5'/B7 _ | |||
Date 1 | |||
i | |||
0. 8. 7d$v i | |||
D. E. Miller 9 /#/87 | |||
Cate~ | |||
" | |||
4- ) | |||
Approved By: C. . r ge , Chief (>//f/87 | |||
Facilities Radiation Protection Date | |||
Section | |||
1 | |||
Inspection Summary | |||
Inspection oli April 28 through May 19, 1987 (Reports No. 50-266/87011(DRSS); | |||
No. 50-301/87010(DRSS)) | |||
Areas Inspected: Routine, unannounced inspection of the radiation protection | |||
program during a refueling outage including: organization and management | |||
controls; internal and external exposure controls; posting and access | |||
controls; contamination control; two incidents concerning unplanned radiation | |||
exposures; and previous inspection findings. | |||
Results: Two violations were identified (failure to properly train employees | |||
using a radioactive source - Section 10; failure to clearly label the contents | |||
ofradjoactivematerialinacontainer-Section11). | |||
. | |||
v!P | |||
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DETAILS | |||
1. Persons Contacted | |||
*R. Bredvad, Plant Health Physicist | |||
*D. Johnson, Project Engineer, Nuclear Plant Engineering | |||
*T. Koehler, General Superintendent | |||
*J. Knorr, Regulatory Engineer, Nuclear Plant Engineering | |||
E. Lipke, General Superintendent, Nuclear Plant Engineering | |||
*J. Reisenbuechler,. Superintendent, EQRS | |||
*J. Zach, Plant Manager | |||
*R. Hague, NRC, Senior Resident Inspector | |||
*R. Leemon, NRC, Resident Inspector | |||
The' inspectors also contacted other plant staff during this inspection. | |||
* Denotes those present at one of the exit meetings held on May 8 and 15, | |||
1987. | |||
2. General | |||
The onsite inspection which began at 8:00 a.m., April 28, 1987, was | |||
conducted to examine aspects of the licensee's radiation protection | |||
program during a refueling outage. The inspection included several plant | |||
tours, review of posting and labeling, review of personal internal and | |||
external exposures, and independent inspection efforts by the inspectors. | |||
Also reviewed were selected open items, corrective actions concerning | |||
previous violations, and two incidents concerning unplanned personal | |||
radiation exposures. | |||
3. Licensee Action on Previous Inspection Findings | |||
(Closed) Open Item (266/86016-01; 301/86015-01): Failure to initiate a | |||
report form as required by Procedure No. HP 1.11 when portal monitor | |||
containination alarms are initiated. The licensee has revised HP 1.11 to | |||
better define specific responsibilities for response to portal monitors, | |||
revised Procedure HP 2.1.2 to clarify employee responsibility for frisking | |||
and notification of personnel when contamination is found, and has | |||
initiated a formal training program for security personnel concerning | |||
their responsibility for response to portal monitor alarms. | |||
(Closed) Open Item (266/86016-02; 301/86015-02): Failure to perform | |||
surveys to ensure workers would not exceed 10 CFR 20.103 limits. | |||
Frequency of radiation and contamination surveys were increased in the | |||
waste evaporator feed cubicle area and other areas subject to changing | |||
radiological conditions. Procedure HP 2.5 has been revised to ensure | |||
requirements for work activities will be based on timely and adequate | |||
surveys of radiological conditions. | |||
2 | |||
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i(Closed) Open-Item (266/85017-01; 301/85017-01): . Developkent-of thel 1 | |||
training program for_the RCOs. The licensee has developed and. initiated I | |||
an RC0 training' program that is-INP0Lcertified. , l | |||
i; ) | |||
(0 pen) Open-ItemL(266/85007-01; 301/85007-01): Turnover rate of RC0 staff / ' | |||
" :) | |||
and the effect on staff. stability. See Section 5. 7 | |||
, i | |||
* | |||
4.- Licensee Response to'NRC Concerns I | |||
; | |||
. 1 | |||
During a previous inspection (Inspection Report Nos.'266/86016; 301/86015)1 J j | |||
-programmatic weaknesses concerning health physics coverage, the RWP '! ~1 | |||
: program, reuse of protective clothing, the A0 qualification program and 1 | |||
other HP practices were identified. In a letter to the NRC dated' .] | |||
February 4,.1987, the licensee addressed tris actions that had been, and y | |||
will be..taken to satisfactorily' correct the identified programmatic | |||
weaknesses; including a commitment to implement full time HP' coverage | |||
< within two years. | |||
' | |||
5. Organization, Management Controls, and Staffing | |||
' | |||
The inspectnrs revfewed the= licensee's organization and management l | |||
controls for radistio protection, including changes in the organizational l | |||
structure and staffing, effectiveness of procedures and other management'- | |||
techniques ~used to implement the program, and experience concerning J | |||
self-identification and correction of program implementation weaknesses. | |||
*} l | |||
' | |||
Region -I6was infonned that a corporata ' staff health physicist will ' | |||
assume a newly' created Superintendecit-Health Physics-(S-HP) position at | |||
Point Beach Station effective Jund 1, 1987. The S-HP reports to.the 3 | |||
General' Superintendent with a direct reporting path to< the Plant Manager , | |||
33 ! | |||
as necessary for radiological matters. The Plar,t Health Physicist and the ! | |||
Radwaste Supervisor will report to the S-HP. According to licensee , | |||
representatives, addition of the S-HP is intendedttd aid creation of a | |||
more; professionally oriented radiation protection department. This - | |||
cesponds to' observations and recommendations made by NRC inspectors as a , , | |||
, result of past inspections. | |||
)- ', | |||
During two previoun inspections (Ir.cpection Reports No. 266/85007; | |||
301/8500Fand 266/86004; 301/86004), it was notad that the turnover rate | |||
of the technician staff (RCDs and RCOTs) was significantly higher than | |||
the turnover rate of other Region III licensees. . This turnover rate | |||
affected the' qualification and experience level of the RCO staff and l | |||
. appeared.to diminish the stability and effectiveness of the radiation ' | |||
protection organization. The cause for this turnover rate was attributed | |||
to the RCOT-selection system and salary differential between RCOs and I | |||
other plant workers which tended to discourage RCO retention. Since then, | |||
' | |||
the licensee ' improved RC0 trainee selection, Jetreased the salary | |||
}' differential between RC0's and other plant workers, increased the HP staff, | |||
and is continuing efforts to build a career HP. staff consisting of 12 | |||
or 13 permanent RCOs. However, the RCO's hoJrly Salary remains l3Wer , | |||
than senior chemistry technicians, mechanical maintenance workers, and y | |||
auxiliary operators. | |||
3 | |||
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'The current radiation protection staff, supplemented by HP contractors, | |||
> | |||
appears adequate to sup' port routine radiation protection coverage. | |||
However,.there remains. insufficient staffing of permanent qualified RCOs | |||
to cover nonroutine functions and the licensee must rely on use of health | |||
physics contractors to supplement;the staff during normal and outage | |||
activities. The shortage of RCOs appears to have been a factor in an | |||
extremity exposure event discussed in.Section 10. | |||
The apparent staffing shortage and lack of upgrading of RCOs was | |||
discussed at the exit meeting. (266/85007-01; 301/85007-01) | |||
' | |||
No-violations or deviations were noted. | |||
6. Internal Exposure Control | |||
The inspectors reviewed the licensee's internal exposure control and | |||
assessment programs, including changes to procedures affecting internal | |||
exposure control and personal exposure assessment; determination whether | |||
engineering controls, respiratory equipment, and assessment of individual | |||
. intakes meet regulatory requirements; planning and preparation for | |||
maintenance and refueling tasks including ALARA considerations; and | |||
required records, reports, and notifications. | |||
The licensee's program for controlling internal exposures includes the use | |||
of protective clothing, respirators, and control of surface and airborne | |||
h radioactivity. A selected review of air sample and survey results was | |||
i made; no significant problems were noted other than those noted in | |||
Section 11. | |||
Whole body count (WBC) data was reviewed for counts performed during the | |||
period August 1, 1986 through March 31, 1987, on company and contractor | |||
personnel. Several followup counts were performed on the few persons who | |||
showed elevated initial counts. Followup counting was adequate to verify | |||
that'the 40 MPC-hour control measure was not exceeded. No problems were | |||
noted. | |||
No violations or deviations were identified. | |||
7. Personal Contamination Events | |||
The licensee initiates Personnel Contamination Event Reports for | |||
individual personal contamination events. The report identifies the | |||
individual, date, location of contamination, method of detection, | |||
disposition of the contamination, and possible cause/ source of the | |||
contamination event. This information is entered into a computer program | |||
which permits summarization and trending of several parameters. | |||
The-licensee periodically generates summary sheets that list individual | |||
events by contractor or employee name, location by body or clothing area, | |||
and method of detection of contamination (routine frisk, checkpoint frisk, | |||
portal monitor, or whole body counter). The licensee uses this | |||
information to identify trends, recurrences by individuals, and possible | |||
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programmatic problems. During 1987 through May 6, 1987, there were 50 | |||
events that met.INP0. reporting criteria. The licensee does not currently l | |||
utilize whole body contamination monitors, relying instead upon " friskers." | |||
The licensee.does have several PCM-1 whole body contamination monitors on 4 | |||
order, , Typically, introduction of whole body contamination monitors | |||
increases significantly the. numbers of identified personal contaminations. | |||
The inspectors noted that about half of the personal contamination events | |||
' involved personal clothing. About one third of the clothing events , | |||
involved shorts, and one third undershirts and socks. The inspectors also i | |||
noted that the licensee's prescribed single set of protective clothing | |||
used for working in contamination levels <30,000 dpm/100 cm2 includes | |||
coveralls with untaped side pocket openings and shoe covers that'do not | |||
cover the ankle area. It appears that this prescribed clothing | |||
contributes to the potential for contamination of underwear and socks. | |||
l | |||
According to licensee representatives, the licensee plans to soon begin | |||
use of coveralls which do not have side pocket openings. However, the | |||
inspectors were not apprised of any plans to alter the type of shoe | |||
coverings worn.- This matter will again be reviewed during future routine | |||
radiation protection inspections. (50-266/87011-03; 50-301/87010-03) | |||
No violations or deviations were identified. | |||
8. l | |||
E,xternal Exposure Control and Personal Dosimetry | |||
The inspectors reviewed the licensee's external exposure control and | |||
personal dosimetry to meet refueling outage needs. | |||
For the Unit 1 refueling outage it appeared adequate radiation surveys to | |||
identify radiological conditions were performed and sufficient health | |||
physics coverage was available to control jobs. | |||
The inspectors selectively reviewed Radiation Work Permits (RWPs) and | |||
associated radiation surveys and observed work being done in the | |||
containment; no problems were identified. | |||
The inspectors selectively reviewed exposure records including TLD and | |||
self reading dosimetry results. The records indicate that no person | |||
exceeded regulatory limits. The occupational external dose for the | |||
station in 1986 was 375 person-rem and through April 1987 it was | |||
approximately 260 person-rem, most of which was due to the Unit I | |||
refueling outage. | |||
No violations or deviations were identified. | |||
9 Preplanning - ALARA | |||
For this refueling outage, health physics personnel were involved in | |||
pre-outage reviews and were aware of the major radiation producing jobs in | |||
advance. Outage planners were followed. With the exception of certain | |||
small jobs that were not effectively preplanned, no major difficulties | |||
were encountered. | |||
5 | |||
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.In accordance with Procedure PBNP 3.7.4, radiological reviews were i | |||
performed for certain routine dose activitier for this' outage in. | |||
accordance with radiological conditions and work to be performed. The | |||
application of these' reviews are part of the' licensee's exposure reduction | |||
program, and the use of.the reviews are particularly important during | |||
outage conditions for implementing ALARA. | |||
-10. Radiolouical Incident Involving Unplanned Radiation Exposures | |||
The inspectors reviewed the circumstances surrounding ~an unplanned whole | |||
body radiation exposure to a station employee who unknowingly handled a i | |||
radioactive source on May 10, 1987. During the review, the inspectors. | |||
contacted licensee managers and health physics personnel, and interviewed | |||
the individuals involved in the incident. The inspectors observed | |||
several physical' reenactments of the incident and reviewed the licensee's | |||
investigation findings. Although no overexposures occurred as a result | |||
of.the incident, the radiation dose to one worker's~ hands was close to | |||
the quarterly extremity dose limit. The following subsections describe | |||
the event, causes, licensee and inspector followup, and dose assessment. | |||
This matter will be discussed further with the licensee during an | |||
enforcement meeting scheduled' for June 18, 1987, in the Region III Office. | |||
a. Summary of Event | |||
On Sunday, May 10, 1987, two Radiation Control Operator Trainees | |||
(RCOTs) and a Health Physics Supervisor (HPS) performed functional | |||
tests of two Radiation Monitoring System (RMS) monitors using a i | |||
cesium-137 source. On Monday, May 11, 1987, the licensee became | |||
aware that one of the RCOTs may have received an extremity | |||
overexposure while performing the functional tests. The licensee | |||
informed an NRC resident inspector and a Region III radiation | |||
specialist of the incident on the afternoon of the same day, | |||
and formed a formal investigation committee consisting of the j | |||
General Superintendent, NPERS, the Superintendent-Training, an ! | |||
ISI Engineer, a Project Engineer-Radiological, and a Senior Project j | |||
Engineer-Licensing. ] | |||
The incident occurred while the three workers were performing | |||
functional tests on RMS detectors. The purpose of the tests was to | |||
expose the detectors to a radiation source of sufficient strength to | |||
actuate containment purge valve trips. The shielded source container | |||
" pig" used for these tests has a large removable shield plug in one | |||
end which is removed to expose the radiation source. A nominal 71 | |||
millicurie cesium-137 source is attached to the end of a source plug , | |||
assembly, which is inserted into the " pig" at the end opposite the ! | |||
shield plug. The source plug is much smaller in diameter than the | |||
shield plug. Each plug is prevented from casual removal by a | |||
padlock. The two padlocks were operated by the same High Radiation | |||
Area key. For these tests, the large plug is removed to expose the | |||
monitor to a collimated radiation beam emanating from the radioactive . | |||
' | |||
source. | |||
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6 | |||
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Neither the HPS or the RCOTs had previously_used the " pig"; however, | |||
the HPS had observed the use of.the " pig" to test the IRE-211/212 ! | |||
detectors on one of.the RMSs. None of the three employees were ; | |||
aware or had been instructed that the Cs-137 source was attached to ! | |||
the small plug; they stated that they assumed the two plugs varied -! | |||
in size to allow for different size radiation beams. The " pig" was | |||
not marked to identify the radiation hazard associated with removal | |||
of the' source plug. | |||
b. Chronology of the Incident | |||
On May'.9, 1987, the HPS completed an 11-hour shift at about 5:30 p.m. | |||
At about 8:50 p.m., the HPS, who was the Duty On-Call Supervisor, | |||
received a call from the Duty Radiation Control Operator (RCO) who | |||
was covering the shift with an RCOT. The RCO stated that he had | |||
to leave the site because of a family emergency. The HPS contacted | |||
two of the four available RCOs to find one to cover the remainder , | |||
of the shift; the HPS was unsuccessful. The HPS then called in an | |||
RCOT to join him and the other RCOT onsite to cover the remainder | |||
of the shift. When the HPS arrived onsite, he became aware that his ' | |||
shift was responsible for conducting the functional trip test of the | |||
Unit 1 containment purge valves. The two monitors used to trip the | |||
purge valves are the Unit 1 SPING RMS (IRE-305) located in the Unit 1 | |||
rod drive room and the Unit 1 PNG RMS (IRE-211/212) located in the -l | |||
IRE-211/212 cubicle. Both monitors are exposed to the Cs-137 | |||
radiation source for the test. At about 11:55 p.m., the HPS, | |||
after realizing that he had never conducted or observed a trip test | |||
on the IRE-305 monitor, called an off-duty HPS who provided the | |||
onsite HPS with information concerning the techniques and methods | |||
required to successfully conduct the test; there was no discussion | |||
of use of the Cs-137 source " pig," which the HPS had observed in use | |||
once previously. | |||
At about 12:30 a.m. on May 10, 1987, the three workers arrived at | |||
the Unit I rod drive room to conduct the functional trip test of | |||
IRE-305. At this point, there are two differing accounts of how the | |||
test was performed, one by the two RCOTs and one by the HPS. | |||
According to the RCOTs, the HPS performed the test at the back side | |||
of IRE-305 by removing the small (source) plug from the " pig," | |||
setting it on the floor, and directing the open plug end of the pig | |||
toward the shielded IRE-305 monitor. Based on the HPS recollection | |||
of the performance of the test, the RCOTs successfully conducted the | |||
test on the front side of IRE-305 by removing the large (shield) | |||
plug. After the control room ir. formed the workers the test was | |||
successful, the plug which had been removed was returned to the pig | |||
and the workers departed the area. | |||
The licensee later demonstrated that if the radioactive plug was on | |||
the floor and not in the " pig" for the test, there would still be | |||
sufficient radiation emitted from the unshielded source to cause the | |||
containment purge valves to trip closed. These different scenarios / | |||
described by the HPS and the RCOTs also were noted during physical , | |||
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reenactments. Although the discrepancies concerning the performance | |||
of this test are significant in their degree of disagreement, it | |||
appears thatleven if the small plug was removed from the pig as | |||
described by the RCOTs the length of time and manner in which it | |||
, | |||
was handled'would not have caused significant' personal exposure to | |||
the'HPS. | |||
At about 1:00 a.m. , the three employees began the trip test on | |||
channel IRE-212 on the PNG monitor located in the IRE-211/212 | |||
cubicle. To conduct the test, one RCOT positioned himself behind | |||
the monitor. His job was to position the " pig" to ditect the- | |||
radiation beam from the open end of the pig at channel IRE-212. | |||
The other RCOT was positioned at the side of the monitor near the | |||
first RCOT to physically assist and to make radiation surveys. The | |||
HPS was located at the front of the monitor and was in radio contact | |||
with the control room. To begin the test, the first RCOT apparently | |||
renoved the source plug, placed it in front of him on the monitor | |||
support (pallet) and attempted to trip the purge valve by pointing | |||
the open port of the " pig" at the monitor. After several . failed | |||
attempts to trip the system, the HPS changed positions with the . | |||
' | |||
second RCOT so he could assist in the " pig" handling. During the | |||
time the HPS and the second RCOT changed positions, the first RCOT | |||
held the source plug for approximately 30 seconds in each hand. He | |||
stated that he was unaware that either plug was a radioactive source; | |||
he assumed the source plug was merely another shield plug. The | |||
other RCOT did not recognize the error even though he measured | |||
abnormally high general area radiation levels (200 - 300 mR/hr) when | |||
the " pig" was incorrectly used; he stated he was unfamiliar with | |||
radiation levels to be expected during the evolution. | |||
After the HPS haa exchanged positions, the first RCOT apparently | |||
re-installed the small (source) plug in the pig and removed the | |||
larger (shield) plug so the test could be performed using what he | |||
assumed to be a larger beam size. After additional monitor | |||
manipulation with the large plug removed and the small plug | |||
positioned in the pig, the control room reported the purge valve | |||
. tripped closed; the large plug was subsequently returned to the pig. | |||
The workers departed from the area assuming that although they l | |||
encountered some difficulty in tripping the valves, the tests were | |||
' | |||
successfully completed and no unusual incidents or circumstances | |||
had occurred. | |||
The licensee became aware of the radiation exposure problem on | |||
Monday, May 11, 1987, when the two RCOTs were casually discussing | |||
their weekend work activities with other members of the health | |||
physics staff. During these discussions, some staff members | |||
realized a significant radiation exposure may have occurred; they | |||
so informed health physics management personnel. The licensee then | |||
formed a formal investigation committee to review the incident. The | |||
committee conducted several physical reenactments of the events, | |||
interviewed all personnel involved in or with the event, and | |||
performed radiation dose assessments. | |||
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10 CFR 19.12 requires that workers receive instruction in | |||
precautions or procedures to minimize exposure and in the purposes | |||
and functions of protective devices employed. The failure to- ( | |||
instruct the workers.in the proper use of the cesium-137 shielded H | |||
source container is a violation of 10 CFR 19 requirements. ! | |||
.(50-266/87011-01; 50-301/87010-01) | |||
l | |||
c. Dose Assessment | |||
. | |||
a | |||
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The licensee calculated whole body and extremity exposures _for each ! | |||
of the workers involved in the incident. The dose assessments were l | |||
calculated based on reenactments (witnessed by NRC inspectors), | |||
sourc'e output and configuration, time of exposure to the source, and , | |||
location of the source relative to the workers, j | |||
For the whole body, the results of the calculations indicate the | |||
highest dose was approximately 660 mrem to the knees of the RCOT who | |||
performed the tests on RE-211/212. Adding previous doses, the RCOT's | |||
whole body exposure was less than 900 mrem for the calendar. quarter; | |||
no regulatory whole body dose limit was exceeded. The inspectors | |||
agree with the licensee's whole body dose assessments. | |||
The only significant extremity dose was_to the hands of the RCOT who | |||
held the source. The licensee calculated this individual's | |||
extremity dose using a modified "QAD". computer code which divides | |||
the volume source into multiple point sources then calculates dose | |||
_ | |||
l | |||
from each point source to the skin. The licensee calculated a | |||
maximum contact dose of approximately 17.5 rem based on the specific | |||
source characteristics, a 33-second exposure time, and 7 mg/cm2 dead | |||
skin layer. Independent NRC calculations based on generalized | |||
source characteristics and the remaining assumptions utilized by the | |||
license resulted in an approximate maximum contact dose of 18.75 rem. , | |||
Assuming the correctness of the licensee's computer code, their ; | |||
calculation should be more accurate than the NRC derived value, | |||
which was based on approximate source characteristics. Based on the | |||
realistically conservative assumption that the individual's hand was | |||
in contact with the surface of the cylindrical source and using the | |||
contact dose rate distribution derived by the licensee's computer | |||
code, the maximum dose to 1 cmi of skin tissue at a depth of 7 mg/cm2 | |||
is approximately 15 rem. (While technical arguments may be made to | |||
utilize less conservative assumptions than 1 cm2 skin area and | |||
7 mg/cm2 dead skin layer, these values are specified by NRC as noted | |||
in IE Information Notice No. 86-23. | |||
The applicable NRC dose limit is 18.75 rems per quarter. Although | |||
the extremity dose in this incident (15 rem) did not exceed | |||
regulatory limits, such outcome appears fortuitous rather than | |||
having derived from licensee planning, training, or precautions. | |||
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' d .' - ' Factors' Contributing to' Incident's Occu'rrence | |||
As a result'of the.. licensee's investigation and the inspectors' | |||
review ~of the incident, several major factors were identified which | |||
appear.to have contributed to the source handling incident. | |||
* -The source container (pig) had no caution markings to identify - | |||
the radiation hazard associated with the removal of the source | |||
plug. The two plugs are similar by outward appearance, with | |||
only the plug diameters differing. Both plugs are locked by | |||
similar key locks that are opened by the same key. | |||
* The HPS and the RCOTs were untrained and inexperienced in the | |||
use of the source container and in the function and calibration | |||
of the RMS. The HPS was unable to provide sufficient technical | |||
information to the RCOTs concerning the job they performed, ; | |||
used poor judgement in performing a job for which he was | |||
unqualified, and may have been fatigued. The relatively low | |||
number of qualified RCOs available to provide health physics | |||
coverage also appears to have been contributary. | |||
* There were no procedures covering the use of the source for | |||
functional testing of the RMS channels. Although the licensee | |||
recently developed a formal training plan which covers the use | |||
of the source container, none of the three participants had | |||
attended the training sessions. | |||
11. Hot Particle Incident | |||
On April 21, 1987, two contractor health physics technicians were assigned | |||
to move bags of radwaste from one temporary storage location to another. | |||
After the task was done and their protective coveralls drycleaned, hot | |||
particles were found in the breast pockets of the coveralls they had | |||
worn. The licensee performed a followup investigation to determine the | |||
activity of the hot particles, the isotopes in the particles, and the | |||
length of time the particles were in the pockets. The inspectors | |||
interviewed.the participants in the incident, reviewed the licensee's | |||
investigation results and calculational methods, and performed , | |||
independent calculations. No overexposures occurred as a result of the l | |||
incident, and no items of noncompliance with regulatory requirements were l | |||
identified; however, weaknesses were noted. The licensee's investigation j | |||
appeared timely and thorough. This matter will be discussed further with i | |||
the licensee during an enforcement meeting scheduled for June 18, 1987, | |||
in the Region III Office. | |||
a. Sequence of Events On April 21, 1987, unusually high contamination , | |||
levels were found on two pairs of protective coveralls while frisking j | |||
them after dry cleaning. No other contaminated PCs were found nor l | |||
was any significant contamination found in the laundry room or the ) | |||
dry cleaning system. The PCs were apparently worn by two I | |||
technicians while moving bags of radwaste in the radwaste building | |||
earlier that day. The contamination was subsequently identified as | |||
several discrete fuel particles. | |||
10 1 | |||
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Direct radiation and contamination surveys of the health physics. | |||
' station, locker. room, maintenance shop, radwaste truck access, and | |||
radwaste ATCOR areas were made to identify the source of the | |||
contamination and determine if'any contamination had been spread to | |||
clean areas. No significant activity was found except in a portion | |||
of the ATCOR area of.the radwaste building where the two contract | |||
technicians had worked earlier that day. | |||
After reporting to work on the morning of April 21, 1987, the senior | |||
and junior contractor health physics technicians were instructed to ! | |||
remove bagged radwaste materials from behind a temporary shield wall | |||
in the ATCOR area of the radwaste building; the bags were to be | |||
transferred into a shielding cask'in the nearby truck. bay. The bagged | |||
materials had been placed behind the shield wall over the preceding | |||
two and a half years because their elevated radiation levels and/or | |||
radioisotopic composition dictated a need for special packaging. | |||
The bags were being moved so that the area could be used to store | |||
other_radwaste. The two contractor technicians, who were working | |||
under the direction of the chemistry group radwaste supervisor, were | |||
to move the bags and provide their'own health physics job coverage. | |||
At about 0750 hours on April 21, 1987, the senior contractor | |||
technician initiated a Radiation Work Permit (RWP) for the bag | |||
handling. The radiological conditions he entered on the RWP *:!ere | |||
based on a survey he had performed in the general area on April 7, i | |||
1987. The general area survey did not include dose rate or i | |||
contamination levels within the temporary shielded area even though | |||
entry into that area would be required. One set of protective | |||
clothing was prescribed. Extensive dosimetry for the chest area, | |||
hands, and forearms was prescribed including integrating alarming | |||
dosimeters (set at 65 mR) to be worn on the chest area of each | |||
technician. No respiratory protective devices were worn or | |||
prescribed. The proper RWP authorizing approvals were obtained. | |||
At about 0800 hours the technicians donned the prescribed protective | |||
clothing, attached their dosimetry, proceeded to the work area, | |||
posted a copy of the RWP at the work site, and unlocked the High j | |||
Radiation Area (HRA) gate at the shielded storage room in which the | |||
temporary shielded area is constructed in a corner. The temporary | |||
shielded walled area is about six feet high and is built of solid | |||
concrete blocks supported / braced with scaffolding; the scaffolding | |||
is so arranged that a person can climb in and out and bags can be | |||
suspended from a horizontal scaffolding railing that is slightly | |||
higher than the block wall. j | |||
Using an extended probe radiation survey instrument, the senior | |||
technician surveyed the shielded storage room while entering to | |||
verify the exposure rates. He then looked into the temporary | |||
shielded storage area and saw about eight bags of waste, three of | |||
which had attached ropes that were tied to a horizontal scaffolding | |||
railing above the block wall. The technicians discussed possible | |||
11 l | |||
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handling methods,. assembled plastic bags, and contacted the control | |||
room to inform them that bags with high radiation readings would be | |||
handled and transported. | |||
l | |||
The senior. technician then pulled out one tied-off bag, transferred | |||
it to the step-off pad (SOP) at the HRA gate where the junior | |||
technician (on the clean side of the SOP) had a plastic bag ready | |||
to " bag-out" the transferred bag. The junior technician then taped > | |||
the outer bag and monitored the radiation level on the bag. The, | |||
': | |||
senior technician removed his low-cut shoe covers and cotton gloves | |||
at the S0P, donned clean cotton gloves, and carried the bag to the | |||
.' | |||
shielding cask in the truck bay. This process was repeated for the | |||
other two tied-off bags. The senior technician then surveyed the | |||
general radiation fields inside the temporary storage area, while | |||
standing.on-scaffolding, using the extended probe survey instrument- | |||
. | |||
1 | |||
the general area radiation exposure rate was 80-100 mR/hr. The t | |||
senior technician then climbed into the temporary storage area, | |||
handed the remaining four bags over the wall to the junior technician, | |||
- | |||
, | |||
then climbed out. The junior technician then followed the 50P ; | |||
procedure and the four bags were transferred to the shielding cask | |||
" | |||
in the same manner at the first three. The HRA gate was relocked, | |||
and the shielding cask surveyed to assure adequate postings and ; | |||
access controls. ; | |||
It is the licensee's practice when one set of protective clothing'is l | |||
worn that the low cut rubber shoe covers remain on the hot side of f | |||
the SOP, the cotton gloves are placed in a receptacle at the SOP, | |||
and the coveralls and low cut plastic shoe covers are worn back to l | |||
the access control area where the coveralls are surveyed to see if l | |||
they.are acceptably clean to be placed in the wearer's controlled !' | |||
side locker for reuse. The plastic' shoe covers are discarded. The | |||
technicians followed this practice. As the junior technician | |||
approached a portable frisker with his hands, the alarm (set at | |||
100 cpm above background) alarmed; the technician switched the | |||
frisker meter range from the X1 to the X10 range and began surveying i | |||
the arms of the coveralls when the alarm sounded again. Both | |||
technicians then discarded their coveralls in the dirty laundry ' | |||
container and began whole body frisking with portable friskers. The | |||
junior technician identified about 200 cpm on his left wrist, | |||
300 cpm on his shorts, 200 cpm on his socks and 3000 cpm on his | |||
shoes. The senior technician identified about 200 cpm on the heel | |||
of one shoe. The technician then followed normal decontamination | |||
" | |||
and documentation procedures. The personal contamination | |||
documentation was taken to a health physics foreman who reviewed the | |||
documentation. The technicians did not tell the RCOs that their | |||
protective coveralls contained highly elevated contamination levels i | |||
when placed in the dirty laundry drum. | |||
As previously stated, the technicians wore extensive self-reading | |||
dosimetry on their chest and wrists including an integrating , | |||
alarming dosimeter on the chest of each technician. The highest | |||
reading thus recorded was 80 mR to the right wrist of the senior | |||
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contra'ctor technician who had performed the majority of the handling | |||
of._the radwaste bags. The indicated exposures appeared reasonable | |||
for the job performed. l | |||
b. Source and Isotopic Content of Contamination (Hot Particles). | |||
During surveys performed in the shielded storage room and vicinity | |||
on the afternoon of April 21, 1987, and on April 22, 1987, several | |||
" hot" particles were identified on the floor of the storage room, | |||
and one on the ladder'used while placing the radwaste bags in the : | |||
shielding cask. No additional particles were found in areas | |||
traversed by the technicians during or after performance of the ; | |||
radwaste bag handing. The " hot" particles read up to 40 R/hr when | |||
- | |||
measured at one inch with an R02A survey meter with the beta- , | |||
. window closed. The particles were small but generally visible with ! | |||
the naked eye. The licensee collected samples of the particles for , | |||
isotopic analysis. | |||
Licensee representatives removed the bags from the shielding cask | |||
where they were placed by the contract technicians. The bags were | |||
observed to see if any had been breached. The licensee noted that | |||
the inner bags (three layers), containing a small filter, appeared | |||
to be slit. The representative took a contamination swipe of the | |||
area surrounding the slits in the inner bags. The swipe was retained | |||
for isotopic analysis. According to the contract technicians, the | |||
plastic bags containing the small filter were the last handled and | |||
transferred to the shielding cask. | |||
The licensee performed further surveys on the two pairs of coveralls | |||
that were retained because of contamination levels. The~ licensee | |||
found two hot particles in the breast pocket of each pair. There | |||
was total radioactivity of 14.2 pCi in the pocket of one pair of the | |||
coveralls and 2.8 pCi in the other. | |||
~ | |||
According to the licensee, the subject filter is a "swarp" filter | |||
from a portable underwater cleaning system. The filter is | |||
essentially a stainer through which circulated water flows while | |||
cleaning underwater debris. The filter sits in a hose coupling | |||
fitting and is under water when the cleaning system is in use. The | |||
filter is cylindrical, about three inches in diameter, five inches | |||
high, has a handling bail on top, and has a thin metal flange | |||
seating surface on the bail end. The licensee believes that the | |||
filter was used during the Unit 2 outage in 1985 to remove debris | |||
' | |||
from the reactor vessel, and has probably been in the shielded | |||
storage area since November 1987. | |||
Using gamma analysis techniques, the licensee determined that the | |||
isotopic content of the hot particles found in the coverall pockets, | |||
floor of the shielded storage area, and swipe taken on the bag | |||
containing the "swarp" filter was mainly Ce-144, Pr-144, Rh-106, , | |||
Ru-106, and Cs-137; the relative abundance of the isotopes was | |||
similar. The isotopic content indicates that the original source | |||
of the particles was past failed fuel, particles of which were i | |||
collected in the "swarp" filter during incore cleaning. | |||
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c. Calculated Dose to Contractor Technicians | |||
Skin doses were calculated by NRC using the VARSKIN computer code | |||
(draft NURGEG/CR 4418 at a skin " depth" of 7 mg/cm2 averaged over | |||
1 cm2 .(IE Information Notice 86-23). Sheilding provided by clothing | |||
was measured by the licensee to be 27 mg/cm2 for one of the workers | |||
and 39 mg/cm 2 for the other. Gamma doses were assumed to be | |||
negligible. | |||
Through discussions, re-enactments, and determination that the hot | |||
particles were released while the technicians handled the last bag | |||
removed from the temporary shielded area, the licensee estimated | |||
that the hot particles were in the technicians' coverall pockets for | |||
a maximum of 15 minutes while the coveralls were being worn. | |||
Because the hot particles were in a coverall pocket and not | |||
stationary on the skin the maximum calculated dose to 1 cm 2 can be | |||
halved based on a conservative estimate of lateral movement of the | |||
coveralls, and further reduced because the coveralls were reasonably | |||
not always in contact with the technician's skin. By conservatively | |||
estimating that the coverall pocket was one centimeter from the | |||
skin for half of the 15 minutes, a dose reduction factor of about | |||
15 results for 50% of the exposure time. Based on these assumptions | |||
and the licensee determined particle activities 14.2 pCi and 2.8 pCi | |||
and isotopic compositions, the calculated skin doses to the two | |||
workers were 4.5 rem and 0.75 rem, respectively. | |||
The licensee's calculated skin doses, based on a licensee modified QAD | |||
computer code and the above assumptions, were 3.5 rem and 0.5 rem, | |||
respectively. The licensee and NRC calculations are in reasonable | |||
agreement. | |||
The applicable NRC dose limit is 7.5 rems per quarter. Although the | |||
maximum skin dose in this incident (4.5 rem) did not exceed | |||
regulatory limits, such outcome appears fortuitous rather than | |||
having derived from licensee planning, training, or precautions. | |||
No violations were identified. | |||
d. Apparent Programmatic Weaknesses Associated with this Event | |||
During the inspectors' review of this incident, several associated | |||
matters appeared to contribute to the incident's occurrence, its | |||
severity, and the eventual promptness of followup investigations. | |||
These matters include: | |||
* The "swarp" filter was used during vacuuming of a reactor | |||
vessel and contained readily dispersible highly radioactive | |||
particles, yet it was not packaged so there would be a low | |||
probability of package damage and resulting contamination | |||
spread. | |||
14 | |||
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* | |||
The "swarp" filter is estimated to have read approximately | |||
25 R/hr when removed from the reactor vessel and transported to | |||
the temporary storage area, yet the bag was apparently not well | |||
marked / identified nor was the outside of the temporary shield | |||
area posted with an instructional posting to indicate its | |||
relative hazard. The method of handling during transport to | |||
the storage area could not be established. | |||
* | |||
There was no inventory of the contents of the temporary | |||
shielded area even though the contents were placed there | |||
. | |||
i | |||
because of the need for special handling and disposal. | |||
* | |||
The contractor senior technician prescribed a single set of | |||
protective clothing with no respirator even though he was | |||
unaware of the contents of the bagged material. He apparently | |||
assumed proper past handling of the bagged material and | |||
anticipated that no handling problems would arise. | |||
* | |||
The technicians knew that one set of coveralls was contaminated | |||
to a significantly greater extent than would be expected for | |||
the work they performed, but did not so inform the RCOs. Such | |||
information would have prompted an earlier start to the | |||
investigation. Had hot particles been deposited on the cold | |||
side of the S0P during the bag-out procedure, earlier followup | |||
would have reduced the potential for contamination spread. | |||
It is noteworthy that until about April 1, 1987, there was no firm | |||
requirement for individuals to survey protective coveralls before | |||
placing them in their controlled zone locker, and to place them in | |||
the laundry hamper if contamination levels exceed 2,000 cpm using | |||
an HP-210 probe. At the request of NRC Region III, the licensee | |||
instituted the coverall frisking policy and revised Procedure HP 2.7 | |||
" General Use of Protective Clothing" to include the requirement. | |||
Had this policy not been changed the contaminated PCs would have | |||
probably been reused with resultant greatly increased personal | |||
exposures. | |||
Failure to identify the package contents with a clearly visible ) | |||
label or readily available record providing sufficient information l | |||
to permit individuals handling the package to take adequate ! | |||
precautions to minimize their exposure is a violation j | |||
with 10 CFR 20.203(f) requirements (Violation 266/87011-02; i | |||
301/87010-02). I | |||
12. Exit Interview | |||
The inspectors met with licensee representatives (denoted in Paragraph 1) | |||
at the conclusion of the inspection and summarized the scope and findings | |||
of the inspection activities. The inspectors also discussed the likely | |||
informational contents of the inspection report with regard to documents I | |||
or processes reviewed by the inspectors during the inspection. The l | |||
licensee did not identify any such documents or processes as ' | |||
proprietary. In response to the inspectors' comments, the licensee: l | |||
l | |||
15 ! | |||
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a. ~ Acknowledged the inspectors comments ~concerning the. identified. | |||
i | |||
weaknesses which. contributed to unplanned personal exposures | |||
.(Sections 10 and 11). | |||
"' | |||
b .-- -Stated that results of the_ investigation and dose evaluations | |||
concerning the personal unplanned exposures would be made available | |||
to Region:III_(Sections 10_and'11). | |||
c. Stated-that efforts will be' continued to increase the' number off | |||
permanent RCOs on the Radiation Department staff (Section 5). | |||
j | |||
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I- 16 | |||
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}} |
Latest revision as of 06:52, 5 March 2022
ML20215G320 | |
Person / Time | |
---|---|
Site: | Point Beach ![]() |
Issue date: | 06/15/1987 |
From: | Greger L, Miller D, Paul R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
To: | |
Shared Package | |
ML20215G310 | List: |
References | |
50-266-87-11, 50-301-87-10, IEIN-86-023, IEIN-86-23, NUDOCS 8706230213 | |
Download: ML20215G320 (16) | |
See also: IR 05000266/1987011
Text
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U. S. NUCLEAR REGULATORY COMMISSION
REGION III
Reports No. 50-266/87011(DRSS); 50-301/87010(DRSS)
Docket Nos. 50-266; 50-301 Licenses No. DPR-24; No. DPR-27
.
Licensee: Wisconsin Electric Power Company
231 West Michigan
Milwaukee, WI 53201
Facility Name: Point Beach Nuclear Plant (PBNP)
Inspection At: PBNP; Units 1 and 2, Two Rivers, Wisconsin
Inspection Conducted: April 28 through May 19, 1987 l
Inspector: 6//5'/B7 _
Date 1
i
0. 8. 7d$v i
D. E. Miller 9 /#/87
Cate~
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4- )
Approved By: C. . r ge , Chief (>//f/87
Facilities Radiation Protection Date
Section
1
Inspection Summary
Inspection oli April 28 through May 19, 1987 (Reports No. 50-266/87011(DRSS);
No. 50-301/87010(DRSS))
Areas Inspected: Routine, unannounced inspection of the radiation protection
program during a refueling outage including: organization and management
controls; internal and external exposure controls; posting and access
controls; contamination control; two incidents concerning unplanned radiation
exposures; and previous inspection findings.
Results: Two violations were identified (failure to properly train employees
using a radioactive source - Section 10; failure to clearly label the contents
ofradjoactivematerialinacontainer-Section11).
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DETAILS
1. Persons Contacted
- R. Bredvad, Plant Health Physicist
- D. Johnson, Project Engineer, Nuclear Plant Engineering
- T. Koehler, General Superintendent
- J. Knorr, Regulatory Engineer, Nuclear Plant Engineering
E. Lipke, General Superintendent, Nuclear Plant Engineering
- J. Reisenbuechler,. Superintendent, EQRS
- J. Zach, Plant Manager
- R. Hague, NRC, Senior Resident Inspector
- R. Leemon, NRC, Resident Inspector
The' inspectors also contacted other plant staff during this inspection.
- Denotes those present at one of the exit meetings held on May 8 and 15,
1987.
2. General
The onsite inspection which began at 8:00 a.m., April 28, 1987, was
conducted to examine aspects of the licensee's radiation protection
program during a refueling outage. The inspection included several plant
tours, review of posting and labeling, review of personal internal and
external exposures, and independent inspection efforts by the inspectors.
Also reviewed were selected open items, corrective actions concerning
previous violations, and two incidents concerning unplanned personal
radiation exposures.
3. Licensee Action on Previous Inspection Findings
(Closed) Open Item (266/86016-01; 301/86015-01): Failure to initiate a
report form as required by Procedure No. HP 1.11 when portal monitor
containination alarms are initiated. The licensee has revised HP 1.11 to
better define specific responsibilities for response to portal monitors,
revised Procedure HP 2.1.2 to clarify employee responsibility for frisking
and notification of personnel when contamination is found, and has
initiated a formal training program for security personnel concerning
their responsibility for response to portal monitor alarms.
(Closed) Open Item (266/86016-02; 301/86015-02): Failure to perform
surveys to ensure workers would not exceed 10 CFR 20.103 limits.
Frequency of radiation and contamination surveys were increased in the
waste evaporator feed cubicle area and other areas subject to changing
radiological conditions. Procedure HP 2.5 has been revised to ensure
requirements for work activities will be based on timely and adequate
surveys of radiological conditions.
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i(Closed) Open-Item (266/85017-01; 301/85017-01): . Developkent-of thel 1
training program for_the RCOs. The licensee has developed and. initiated I
an RC0 training' program that is-INP0Lcertified. , l
i; )
(0 pen) Open-ItemL(266/85007-01; 301/85007-01): Turnover rate of RC0 staff / '
" :)
and the effect on staff. stability. See Section 5. 7
, i
4.- Licensee Response to'NRC Concerns I
. 1
During a previous inspection (Inspection Report Nos.'266/86016; 301/86015)1 J j
-programmatic weaknesses concerning health physics coverage, the RWP '! ~1
- program, reuse of protective clothing, the A0 qualification program and 1
other HP practices were identified. In a letter to the NRC dated' .]
February 4,.1987, the licensee addressed tris actions that had been, and y
will be..taken to satisfactorily' correct the identified programmatic
weaknesses; including a commitment to implement full time HP' coverage
< within two years.
'
5. Organization, Management Controls, and Staffing
'
The inspectnrs revfewed the= licensee's organization and management l
controls for radistio protection, including changes in the organizational l
structure and staffing, effectiveness of procedures and other management'-
techniques ~used to implement the program, and experience concerning J
self-identification and correction of program implementation weaknesses.
- } l
'
Region -I6was infonned that a corporata ' staff health physicist will '
assume a newly' created Superintendecit-Health Physics-(S-HP) position at
Point Beach Station effective Jund 1, 1987. The S-HP reports to.the 3
General' Superintendent with a direct reporting path to< the Plant Manager ,
33 !
as necessary for radiological matters. The Plar,t Health Physicist and the !
Radwaste Supervisor will report to the S-HP. According to licensee ,
representatives, addition of the S-HP is intendedttd aid creation of a
more; professionally oriented radiation protection department. This -
cesponds to' observations and recommendations made by NRC inspectors as a , ,
, result of past inspections.
)- ',
During two previoun inspections (Ir.cpection Reports No. 266/85007;
301/8500Fand 266/86004; 301/86004), it was notad that the turnover rate
of the technician staff (RCDs and RCOTs) was significantly higher than
the turnover rate of other Region III licensees. . This turnover rate
affected the' qualification and experience level of the RCO staff and l
. appeared.to diminish the stability and effectiveness of the radiation '
protection organization. The cause for this turnover rate was attributed
to the RCOT-selection system and salary differential between RCOs and I
other plant workers which tended to discourage RCO retention. Since then,
'
the licensee ' improved RC0 trainee selection, Jetreased the salary
}' differential between RC0's and other plant workers, increased the HP staff,
and is continuing efforts to build a career HP. staff consisting of 12
or 13 permanent RCOs. However, the RCO's hoJrly Salary remains l3Wer ,
than senior chemistry technicians, mechanical maintenance workers, and y
auxiliary operators.
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'The current radiation protection staff, supplemented by HP contractors,
>
appears adequate to sup' port routine radiation protection coverage.
However,.there remains. insufficient staffing of permanent qualified RCOs
to cover nonroutine functions and the licensee must rely on use of health
physics contractors to supplement;the staff during normal and outage
activities. The shortage of RCOs appears to have been a factor in an
extremity exposure event discussed in.Section 10.
The apparent staffing shortage and lack of upgrading of RCOs was
discussed at the exit meeting. (266/85007-01; 301/85007-01)
'
No-violations or deviations were noted.
6. Internal Exposure Control
The inspectors reviewed the licensee's internal exposure control and
assessment programs, including changes to procedures affecting internal
exposure control and personal exposure assessment; determination whether
engineering controls, respiratory equipment, and assessment of individual
. intakes meet regulatory requirements; planning and preparation for
maintenance and refueling tasks including ALARA considerations; and
required records, reports, and notifications.
The licensee's program for controlling internal exposures includes the use
of protective clothing, respirators, and control of surface and airborne
h radioactivity. A selected review of air sample and survey results was
i made; no significant problems were noted other than those noted in
Section 11.
Whole body count (WBC) data was reviewed for counts performed during the
period August 1, 1986 through March 31, 1987, on company and contractor
personnel. Several followup counts were performed on the few persons who
showed elevated initial counts. Followup counting was adequate to verify
that'the 40 MPC-hour control measure was not exceeded. No problems were
noted.
No violations or deviations were identified.
7. Personal Contamination Events
The licensee initiates Personnel Contamination Event Reports for
individual personal contamination events. The report identifies the
individual, date, location of contamination, method of detection,
disposition of the contamination, and possible cause/ source of the
contamination event. This information is entered into a computer program
which permits summarization and trending of several parameters.
The-licensee periodically generates summary sheets that list individual
events by contractor or employee name, location by body or clothing area,
and method of detection of contamination (routine frisk, checkpoint frisk,
portal monitor, or whole body counter). The licensee uses this
information to identify trends, recurrences by individuals, and possible
4
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programmatic problems. During 1987 through May 6, 1987, there were 50
events that met.INP0. reporting criteria. The licensee does not currently l
utilize whole body contamination monitors, relying instead upon " friskers."
The licensee.does have several PCM-1 whole body contamination monitors on 4
order, , Typically, introduction of whole body contamination monitors
increases significantly the. numbers of identified personal contaminations.
The inspectors noted that about half of the personal contamination events
' involved personal clothing. About one third of the clothing events ,
involved shorts, and one third undershirts and socks. The inspectors also i
noted that the licensee's prescribed single set of protective clothing
used for working in contamination levels <30,000 dpm/100 cm2 includes
coveralls with untaped side pocket openings and shoe covers that'do not
cover the ankle area. It appears that this prescribed clothing
contributes to the potential for contamination of underwear and socks.
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According to licensee representatives, the licensee plans to soon begin
use of coveralls which do not have side pocket openings. However, the
inspectors were not apprised of any plans to alter the type of shoe
coverings worn.- This matter will again be reviewed during future routine
radiation protection inspections. (50-266/87011-03; 50-301/87010-03)
No violations or deviations were identified.
8. l
E,xternal Exposure Control and Personal Dosimetry
The inspectors reviewed the licensee's external exposure control and
personal dosimetry to meet refueling outage needs.
For the Unit 1 refueling outage it appeared adequate radiation surveys to
identify radiological conditions were performed and sufficient health
physics coverage was available to control jobs.
The inspectors selectively reviewed Radiation Work Permits (RWPs) and
associated radiation surveys and observed work being done in the
containment; no problems were identified.
The inspectors selectively reviewed exposure records including TLD and
self reading dosimetry results. The records indicate that no person
exceeded regulatory limits. The occupational external dose for the
station in 1986 was 375 person-rem and through April 1987 it was
approximately 260 person-rem, most of which was due to the Unit I
refueling outage.
No violations or deviations were identified.
9 Preplanning - ALARA
For this refueling outage, health physics personnel were involved in
pre-outage reviews and were aware of the major radiation producing jobs in
advance. Outage planners were followed. With the exception of certain
small jobs that were not effectively preplanned, no major difficulties
were encountered.
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.In accordance with Procedure PBNP 3.7.4, radiological reviews were i
performed for certain routine dose activitier for this' outage in.
accordance with radiological conditions and work to be performed. The
application of these' reviews are part of the' licensee's exposure reduction
program, and the use of.the reviews are particularly important during
outage conditions for implementing ALARA.
-10. Radiolouical Incident Involving Unplanned Radiation Exposures
The inspectors reviewed the circumstances surrounding ~an unplanned whole
body radiation exposure to a station employee who unknowingly handled a i
radioactive source on May 10, 1987. During the review, the inspectors.
contacted licensee managers and health physics personnel, and interviewed
the individuals involved in the incident. The inspectors observed
several physical' reenactments of the incident and reviewed the licensee's
investigation findings. Although no overexposures occurred as a result
of.the incident, the radiation dose to one worker's~ hands was close to
the quarterly extremity dose limit. The following subsections describe
the event, causes, licensee and inspector followup, and dose assessment.
This matter will be discussed further with the licensee during an
enforcement meeting scheduled' for June 18, 1987, in the Region III Office.
a. Summary of Event
On Sunday, May 10, 1987, two Radiation Control Operator Trainees
(RCOTs) and a Health Physics Supervisor (HPS) performed functional
tests of two Radiation Monitoring System (RMS) monitors using a i
cesium-137 source. On Monday, May 11, 1987, the licensee became
aware that one of the RCOTs may have received an extremity
overexposure while performing the functional tests. The licensee
informed an NRC resident inspector and a Region III radiation
specialist of the incident on the afternoon of the same day,
and formed a formal investigation committee consisting of the j
General Superintendent, NPERS, the Superintendent-Training, an !
ISI Engineer, a Project Engineer-Radiological, and a Senior Project j
Engineer-Licensing. ]
The incident occurred while the three workers were performing
functional tests on RMS detectors. The purpose of the tests was to
expose the detectors to a radiation source of sufficient strength to
actuate containment purge valve trips. The shielded source container
" pig" used for these tests has a large removable shield plug in one
end which is removed to expose the radiation source. A nominal 71
millicurie cesium-137 source is attached to the end of a source plug ,
assembly, which is inserted into the " pig" at the end opposite the !
shield plug. The source plug is much smaller in diameter than the
shield plug. Each plug is prevented from casual removal by a
padlock. The two padlocks were operated by the same High Radiation
Area key. For these tests, the large plug is removed to expose the
monitor to a collimated radiation beam emanating from the radioactive .
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source.
.
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Neither the HPS or the RCOTs had previously_used the " pig"; however,
the HPS had observed the use of.the " pig" to test the IRE-211/212 !
detectors on one of.the RMSs. None of the three employees were ;
aware or had been instructed that the Cs-137 source was attached to !
the small plug; they stated that they assumed the two plugs varied -!
in size to allow for different size radiation beams. The " pig" was
not marked to identify the radiation hazard associated with removal
of the' source plug.
b. Chronology of the Incident
On May'.9, 1987, the HPS completed an 11-hour shift at about 5:30 p.m.
At about 8:50 p.m., the HPS, who was the Duty On-Call Supervisor,
received a call from the Duty Radiation Control Operator (RCO) who
was covering the shift with an RCOT. The RCO stated that he had
to leave the site because of a family emergency. The HPS contacted
two of the four available RCOs to find one to cover the remainder ,
of the shift; the HPS was unsuccessful. The HPS then called in an
RCOT to join him and the other RCOT onsite to cover the remainder
of the shift. When the HPS arrived onsite, he became aware that his '
shift was responsible for conducting the functional trip test of the
Unit 1 containment purge valves. The two monitors used to trip the
purge valves are the Unit 1 SPING RMS (IRE-305) located in the Unit 1
rod drive room and the Unit 1 PNG RMS (IRE-211/212) located in the -l
IRE-211/212 cubicle. Both monitors are exposed to the Cs-137
radiation source for the test. At about 11:55 p.m., the HPS,
after realizing that he had never conducted or observed a trip test
on the IRE-305 monitor, called an off-duty HPS who provided the
onsite HPS with information concerning the techniques and methods
required to successfully conduct the test; there was no discussion
of use of the Cs-137 source " pig," which the HPS had observed in use
once previously.
At about 12:30 a.m. on May 10, 1987, the three workers arrived at
the Unit I rod drive room to conduct the functional trip test of
IRE-305. At this point, there are two differing accounts of how the
test was performed, one by the two RCOTs and one by the HPS.
According to the RCOTs, the HPS performed the test at the back side
of IRE-305 by removing the small (source) plug from the " pig,"
setting it on the floor, and directing the open plug end of the pig
toward the shielded IRE-305 monitor. Based on the HPS recollection
of the performance of the test, the RCOTs successfully conducted the
test on the front side of IRE-305 by removing the large (shield)
plug. After the control room ir. formed the workers the test was
successful, the plug which had been removed was returned to the pig
and the workers departed the area.
The licensee later demonstrated that if the radioactive plug was on
the floor and not in the " pig" for the test, there would still be
sufficient radiation emitted from the unshielded source to cause the
containment purge valves to trip closed. These different scenarios /
described by the HPS and the RCOTs also were noted during physical ,
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reenactments. Although the discrepancies concerning the performance
of this test are significant in their degree of disagreement, it
appears thatleven if the small plug was removed from the pig as
described by the RCOTs the length of time and manner in which it
,
was handled'would not have caused significant' personal exposure to
the'HPS.
At about 1:00 a.m. , the three employees began the trip test on
channel IRE-212 on the PNG monitor located in the IRE-211/212
cubicle. To conduct the test, one RCOT positioned himself behind
the monitor. His job was to position the " pig" to ditect the-
radiation beam from the open end of the pig at channel IRE-212.
The other RCOT was positioned at the side of the monitor near the
first RCOT to physically assist and to make radiation surveys. The
HPS was located at the front of the monitor and was in radio contact
with the control room. To begin the test, the first RCOT apparently
renoved the source plug, placed it in front of him on the monitor
support (pallet) and attempted to trip the purge valve by pointing
the open port of the " pig" at the monitor. After several . failed
attempts to trip the system, the HPS changed positions with the .
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second RCOT so he could assist in the " pig" handling. During the
time the HPS and the second RCOT changed positions, the first RCOT
held the source plug for approximately 30 seconds in each hand. He
stated that he was unaware that either plug was a radioactive source;
he assumed the source plug was merely another shield plug. The
other RCOT did not recognize the error even though he measured
abnormally high general area radiation levels (200 - 300 mR/hr) when
the " pig" was incorrectly used; he stated he was unfamiliar with
radiation levels to be expected during the evolution.
After the HPS haa exchanged positions, the first RCOT apparently
re-installed the small (source) plug in the pig and removed the
larger (shield) plug so the test could be performed using what he
assumed to be a larger beam size. After additional monitor
manipulation with the large plug removed and the small plug
positioned in the pig, the control room reported the purge valve
. tripped closed; the large plug was subsequently returned to the pig.
The workers departed from the area assuming that although they l
encountered some difficulty in tripping the valves, the tests were
'
successfully completed and no unusual incidents or circumstances
had occurred.
The licensee became aware of the radiation exposure problem on
Monday, May 11, 1987, when the two RCOTs were casually discussing
their weekend work activities with other members of the health
physics staff. During these discussions, some staff members
realized a significant radiation exposure may have occurred; they
so informed health physics management personnel. The licensee then
formed a formal investigation committee to review the incident. The
committee conducted several physical reenactments of the events,
interviewed all personnel involved in or with the event, and
performed radiation dose assessments.
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10 CFR 19.12 requires that workers receive instruction in
precautions or procedures to minimize exposure and in the purposes
and functions of protective devices employed. The failure to- (
instruct the workers.in the proper use of the cesium-137 shielded H
source container is a violation of 10 CFR 19 requirements. !
.(50-266/87011-01; 50-301/87010-01)
l
c. Dose Assessment
.
a
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The licensee calculated whole body and extremity exposures _for each !
of the workers involved in the incident. The dose assessments were l
calculated based on reenactments (witnessed by NRC inspectors),
sourc'e output and configuration, time of exposure to the source, and ,
location of the source relative to the workers, j
For the whole body, the results of the calculations indicate the
highest dose was approximately 660 mrem to the knees of the RCOT who
performed the tests on RE-211/212. Adding previous doses, the RCOT's
whole body exposure was less than 900 mrem for the calendar. quarter;
no regulatory whole body dose limit was exceeded. The inspectors
agree with the licensee's whole body dose assessments.
The only significant extremity dose was_to the hands of the RCOT who
held the source. The licensee calculated this individual's
extremity dose using a modified "QAD". computer code which divides
the volume source into multiple point sources then calculates dose
_
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from each point source to the skin. The licensee calculated a
maximum contact dose of approximately 17.5 rem based on the specific
source characteristics, a 33-second exposure time, and 7 mg/cm2 dead
skin layer. Independent NRC calculations based on generalized
source characteristics and the remaining assumptions utilized by the
license resulted in an approximate maximum contact dose of 18.75 rem. ,
Assuming the correctness of the licensee's computer code, their ;
calculation should be more accurate than the NRC derived value,
which was based on approximate source characteristics. Based on the
realistically conservative assumption that the individual's hand was
in contact with the surface of the cylindrical source and using the
contact dose rate distribution derived by the licensee's computer
code, the maximum dose to 1 cmi of skin tissue at a depth of 7 mg/cm2
is approximately 15 rem. (While technical arguments may be made to
utilize less conservative assumptions than 1 cm2 skin area and
7 mg/cm2 dead skin layer, these values are specified by NRC as noted
in IE Information Notice No. 86-23.
The applicable NRC dose limit is 18.75 rems per quarter. Although
the extremity dose in this incident (15 rem) did not exceed
regulatory limits, such outcome appears fortuitous rather than
having derived from licensee planning, training, or precautions.
9
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' d .' - ' Factors' Contributing to' Incident's Occu'rrence
As a result'of the.. licensee's investigation and the inspectors'
review ~of the incident, several major factors were identified which
appear.to have contributed to the source handling incident.
- -The source container (pig) had no caution markings to identify -
the radiation hazard associated with the removal of the source
plug. The two plugs are similar by outward appearance, with
only the plug diameters differing. Both plugs are locked by
similar key locks that are opened by the same key.
- The HPS and the RCOTs were untrained and inexperienced in the
use of the source container and in the function and calibration
of the RMS. The HPS was unable to provide sufficient technical
information to the RCOTs concerning the job they performed, ;
used poor judgement in performing a job for which he was
unqualified, and may have been fatigued. The relatively low
number of qualified RCOs available to provide health physics
coverage also appears to have been contributary.
- There were no procedures covering the use of the source for
functional testing of the RMS channels. Although the licensee
recently developed a formal training plan which covers the use
of the source container, none of the three participants had
attended the training sessions.
11. Hot Particle Incident
On April 21, 1987, two contractor health physics technicians were assigned
to move bags of radwaste from one temporary storage location to another.
After the task was done and their protective coveralls drycleaned, hot
particles were found in the breast pockets of the coveralls they had
worn. The licensee performed a followup investigation to determine the
activity of the hot particles, the isotopes in the particles, and the
length of time the particles were in the pockets. The inspectors
interviewed.the participants in the incident, reviewed the licensee's
investigation results and calculational methods, and performed ,
independent calculations. No overexposures occurred as a result of the l
incident, and no items of noncompliance with regulatory requirements were l
identified; however, weaknesses were noted. The licensee's investigation j
appeared timely and thorough. This matter will be discussed further with i
the licensee during an enforcement meeting scheduled for June 18, 1987,
in the Region III Office.
a. Sequence of Events On April 21, 1987, unusually high contamination ,
levels were found on two pairs of protective coveralls while frisking j
them after dry cleaning. No other contaminated PCs were found nor l
was any significant contamination found in the laundry room or the )
dry cleaning system. The PCs were apparently worn by two I
technicians while moving bags of radwaste in the radwaste building
earlier that day. The contamination was subsequently identified as
several discrete fuel particles.
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Direct radiation and contamination surveys of the health physics.
' station, locker. room, maintenance shop, radwaste truck access, and
radwaste ATCOR areas were made to identify the source of the
contamination and determine if'any contamination had been spread to
clean areas. No significant activity was found except in a portion
of the ATCOR area of.the radwaste building where the two contract
technicians had worked earlier that day.
After reporting to work on the morning of April 21, 1987, the senior
and junior contractor health physics technicians were instructed to !
remove bagged radwaste materials from behind a temporary shield wall
in the ATCOR area of the radwaste building; the bags were to be
transferred into a shielding cask'in the nearby truck. bay. The bagged
materials had been placed behind the shield wall over the preceding
two and a half years because their elevated radiation levels and/or
radioisotopic composition dictated a need for special packaging.
The bags were being moved so that the area could be used to store
other_radwaste. The two contractor technicians, who were working
under the direction of the chemistry group radwaste supervisor, were
to move the bags and provide their'own health physics job coverage.
At about 0750 hours0.00868 days <br />0.208 hours <br />0.00124 weeks <br />2.85375e-4 months <br /> on April 21, 1987, the senior contractor
technician initiated a Radiation Work Permit (RWP) for the bag
handling. The radiological conditions he entered on the RWP *:!ere
based on a survey he had performed in the general area on April 7, i
1987. The general area survey did not include dose rate or i
contamination levels within the temporary shielded area even though
entry into that area would be required. One set of protective
clothing was prescribed. Extensive dosimetry for the chest area,
hands, and forearms was prescribed including integrating alarming
dosimeters (set at 65 mR) to be worn on the chest area of each
technician. No respiratory protective devices were worn or
prescribed. The proper RWP authorizing approvals were obtained.
At about 0800 hours0.00926 days <br />0.222 hours <br />0.00132 weeks <br />3.044e-4 months <br /> the technicians donned the prescribed protective
clothing, attached their dosimetry, proceeded to the work area,
posted a copy of the RWP at the work site, and unlocked the High j
Radiation Area (HRA) gate at the shielded storage room in which the
temporary shielded area is constructed in a corner. The temporary
shielded walled area is about six feet high and is built of solid
concrete blocks supported / braced with scaffolding; the scaffolding
is so arranged that a person can climb in and out and bags can be
suspended from a horizontal scaffolding railing that is slightly
higher than the block wall. j
Using an extended probe radiation survey instrument, the senior
technician surveyed the shielded storage room while entering to
verify the exposure rates. He then looked into the temporary
shielded storage area and saw about eight bags of waste, three of
which had attached ropes that were tied to a horizontal scaffolding
railing above the block wall. The technicians discussed possible
11 l
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handling methods,. assembled plastic bags, and contacted the control
room to inform them that bags with high radiation readings would be
handled and transported.
l
The senior. technician then pulled out one tied-off bag, transferred
it to the step-off pad (SOP) at the HRA gate where the junior
technician (on the clean side of the SOP) had a plastic bag ready
to " bag-out" the transferred bag. The junior technician then taped >
the outer bag and monitored the radiation level on the bag. The,
':
senior technician removed his low-cut shoe covers and cotton gloves
at the S0P, donned clean cotton gloves, and carried the bag to the
.'
shielding cask in the truck bay. This process was repeated for the
other two tied-off bags. The senior technician then surveyed the
general radiation fields inside the temporary storage area, while
standing.on-scaffolding, using the extended probe survey instrument-
.
1
the general area radiation exposure rate was80-100 mR/hr. The t
senior technician then climbed into the temporary storage area,
handed the remaining four bags over the wall to the junior technician,
-
,
then climbed out. The junior technician then followed the 50P ;
procedure and the four bags were transferred to the shielding cask
"
in the same manner at the first three. The HRA gate was relocked,
and the shielding cask surveyed to assure adequate postings and ;
access controls. ;
It is the licensee's practice when one set of protective clothing'is l
worn that the low cut rubber shoe covers remain on the hot side of f
the SOP, the cotton gloves are placed in a receptacle at the SOP,
and the coveralls and low cut plastic shoe covers are worn back to l
the access control area where the coveralls are surveyed to see if l
they.are acceptably clean to be placed in the wearer's controlled !'
side locker for reuse. The plastic' shoe covers are discarded. The
technicians followed this practice. As the junior technician
approached a portable frisker with his hands, the alarm (set at
100 cpm above background) alarmed; the technician switched the
frisker meter range from the X1 to the X10 range and began surveying i
the arms of the coveralls when the alarm sounded again. Both
technicians then discarded their coveralls in the dirty laundry '
container and began whole body frisking with portable friskers. The
junior technician identified about 200 cpm on his left wrist,
300 cpm on his shorts, 200 cpm on his socks and 3000 cpm on his
shoes. The senior technician identified about 200 cpm on the heel
of one shoe. The technician then followed normal decontamination
"
and documentation procedures. The personal contamination
documentation was taken to a health physics foreman who reviewed the
documentation. The technicians did not tell the RCOs that their
protective coveralls contained highly elevated contamination levels i
when placed in the dirty laundry drum.
As previously stated, the technicians wore extensive self-reading
dosimetry on their chest and wrists including an integrating ,
alarming dosimeter on the chest of each technician. The highest
reading thus recorded was 80 mR to the right wrist of the senior
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contra'ctor technician who had performed the majority of the handling
of._the radwaste bags. The indicated exposures appeared reasonable
for the job performed. l
b. Source and Isotopic Content of Contamination (Hot Particles).
During surveys performed in the shielded storage room and vicinity
on the afternoon of April 21, 1987, and on April 22, 1987, several
" hot" particles were identified on the floor of the storage room,
and one on the ladder'used while placing the radwaste bags in the :
shielding cask. No additional particles were found in areas
traversed by the technicians during or after performance of the ;
radwaste bag handing. The " hot" particles read up to 40 R/hr when
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measured at one inch with an R02A survey meter with the beta- ,
. window closed. The particles were small but generally visible with !
the naked eye. The licensee collected samples of the particles for ,
isotopic analysis.
Licensee representatives removed the bags from the shielding cask
where they were placed by the contract technicians. The bags were
observed to see if any had been breached. The licensee noted that
the inner bags (three layers), containing a small filter, appeared
to be slit. The representative took a contamination swipe of the
area surrounding the slits in the inner bags. The swipe was retained
for isotopic analysis. According to the contract technicians, the
plastic bags containing the small filter were the last handled and
transferred to the shielding cask.
The licensee performed further surveys on the two pairs of coveralls
that were retained because of contamination levels. The~ licensee
found two hot particles in the breast pocket of each pair. There
was total radioactivity of 14.2 pCi in the pocket of one pair of the
coveralls and 2.8 pCi in the other.
~
According to the licensee, the subject filter is a "swarp" filter
from a portable underwater cleaning system. The filter is
essentially a stainer through which circulated water flows while
cleaning underwater debris. The filter sits in a hose coupling
fitting and is under water when the cleaning system is in use. The
filter is cylindrical, about three inches in diameter, five inches
high, has a handling bail on top, and has a thin metal flange
seating surface on the bail end. The licensee believes that the
filter was used during the Unit 2 outage in 1985 to remove debris
'
from the reactor vessel, and has probably been in the shielded
storage area since November 1987.
Using gamma analysis techniques, the licensee determined that the
isotopic content of the hot particles found in the coverall pockets,
floor of the shielded storage area, and swipe taken on the bag
containing the "swarp" filter was mainly Ce-144, Pr-144, Rh-106, ,
Ru-106, and Cs-137; the relative abundance of the isotopes was
similar. The isotopic content indicates that the original source
of the particles was past failed fuel, particles of which were i
collected in the "swarp" filter during incore cleaning.
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c. Calculated Dose to Contractor Technicians
Skin doses were calculated by NRC using the VARSKIN computer code
(draft NURGEG/CR 4418 at a skin " depth" of 7 mg/cm2 averaged over
1 cm2 .(IE Information Notice 86-23). Sheilding provided by clothing
was measured by the licensee to be 27 mg/cm2 for one of the workers
and 39 mg/cm 2 for the other. Gamma doses were assumed to be
negligible.
Through discussions, re-enactments, and determination that the hot
particles were released while the technicians handled the last bag
removed from the temporary shielded area, the licensee estimated
that the hot particles were in the technicians' coverall pockets for
a maximum of 15 minutes while the coveralls were being worn.
Because the hot particles were in a coverall pocket and not
stationary on the skin the maximum calculated dose to 1 cm 2 can be
halved based on a conservative estimate of lateral movement of the
coveralls, and further reduced because the coveralls were reasonably
not always in contact with the technician's skin. By conservatively
estimating that the coverall pocket was one centimeter from the
skin for half of the 15 minutes, a dose reduction factor of about
15 results for 50% of the exposure time. Based on these assumptions
and the licensee determined particle activities 14.2 pCi and 2.8 pCi
and isotopic compositions, the calculated skin doses to the two
workers were 4.5 rem and 0.75 rem, respectively.
The licensee's calculated skin doses, based on a licensee modified QAD
computer code and the above assumptions, were 3.5 rem and 0.5 rem,
respectively. The licensee and NRC calculations are in reasonable
agreement.
The applicable NRC dose limit is 7.5 rems per quarter. Although the
maximum skin dose in this incident (4.5 rem) did not exceed
regulatory limits, such outcome appears fortuitous rather than
having derived from licensee planning, training, or precautions.
No violations were identified.
d. Apparent Programmatic Weaknesses Associated with this Event
During the inspectors' review of this incident, several associated
matters appeared to contribute to the incident's occurrence, its
severity, and the eventual promptness of followup investigations.
These matters include:
- The "swarp" filter was used during vacuuming of a reactor
vessel and contained readily dispersible highly radioactive
particles, yet it was not packaged so there would be a low
probability of package damage and resulting contamination
spread.
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The "swarp" filter is estimated to have read approximately
25 R/hr when removed from the reactor vessel and transported to
the temporary storage area, yet the bag was apparently not well
marked / identified nor was the outside of the temporary shield
area posted with an instructional posting to indicate its
relative hazard. The method of handling during transport to
the storage area could not be established.
There was no inventory of the contents of the temporary
shielded area even though the contents were placed there
.
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because of the need for special handling and disposal.
The contractor senior technician prescribed a single set of
protective clothing with no respirator even though he was
unaware of the contents of the bagged material. He apparently
assumed proper past handling of the bagged material and
anticipated that no handling problems would arise.
The technicians knew that one set of coveralls was contaminated
to a significantly greater extent than would be expected for
the work they performed, but did not so inform the RCOs. Such
information would have prompted an earlier start to the
investigation. Had hot particles been deposited on the cold
side of the S0P during the bag-out procedure, earlier followup
would have reduced the potential for contamination spread.
It is noteworthy that until about April 1, 1987, there was no firm
requirement for individuals to survey protective coveralls before
placing them in their controlled zone locker, and to place them in
the laundry hamper if contamination levels exceed 2,000 cpm using
an HP-210 probe. At the request of NRC Region III, the licensee
instituted the coverall frisking policy and revised Procedure HP 2.7
" General Use of Protective Clothing" to include the requirement.
Had this policy not been changed the contaminated PCs would have
probably been reused with resultant greatly increased personal
exposures.
Failure to identify the package contents with a clearly visible )
label or readily available record providing sufficient information l
to permit individuals handling the package to take adequate !
precautions to minimize their exposure is a violation j
with 10 CFR 20.203(f) requirements (Violation 266/87011-02; i
301/87010-02). I
12. Exit Interview
The inspectors met with licensee representatives (denoted in Paragraph 1)
at the conclusion of the inspection and summarized the scope and findings
of the inspection activities. The inspectors also discussed the likely
informational contents of the inspection report with regard to documents I
or processes reviewed by the inspectors during the inspection. The l
licensee did not identify any such documents or processes as '
proprietary. In response to the inspectors' comments, the licensee: l
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a. ~ Acknowledged the inspectors comments ~concerning the. identified.
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weaknesses which. contributed to unplanned personal exposures
.(Sections 10 and 11).
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b .-- -Stated that results of the_ investigation and dose evaluations
concerning the personal unplanned exposures would be made available
to Region:III_(Sections 10_and'11).
c. Stated-that efforts will be' continued to increase the' number off
permanent RCOs on the Radiation Department staff (Section 5).
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