IR 05000293/1984044

Ack Receipt of Informing NRC of Steps Taken to Correct Violations Noted in Insp Repts 50-293/84-44 & 50-293/85-02.Personnel Disregard of Procedural Requirements Indicates Lack of Mgt Oversight of Radiation Controls

ML20127P385
Person / Time
Site:	Pilgrim
Issue date:	06/26/1985
From:	Murley T NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Sweeney S BOSTON EDISON CO.
References
EA-85-018, EA-85-18, NUDOCS 8507020402
Download: ML20127P385 (3)

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JUN 2 61985 Docket No. 50-293 EA 85-18 Boston Edison Company M/C Nuclear ATTN: Stephen J. Sweeney President 800 Boylston Street Boston, Massachusetts 02199 Gentlemen:

Subject: Notice of Violation (NRC Inspection Nos. 50-293/84-44 and 50-293/85-02)

Your letter of April 5,1985 (BECo Ltr No.85-068) transmitted your response to the Notice of Violation (NOV) enclosed wita our letter dated March 6, 1985.

Thank you for providing us the corrective and preventive actions discussed in your letter. We will review the implementation of these actions during a future inspection.

In your letter, you (1) requested that Item A.1.a be eliminated as a violation or at least be reduced in Severity Level; (2) requested that the Severity Level of Items A.1.b, A.1.c, A.2 and B be reduced; and (3) disagreed with our characterization that the primary cause of the incident was a lack of radio-logical controls management oversight.

The NRC maintains that the violations were appropriately classified in the aggregate so as to focus on the underlying cause, namely, a lack of adequate oversight of radiation protection activities as evidenced by multiple and recurrent failures to adhere to procedural requirements. The NRC also main-tains that classification of this aggregate problem at Severity Level III is appropriate because the violations are associated with an event in which a substantial potential existed for an exposure in excess of the regulatory limit. This potential existed because an individual entered a tank where high radiation levels existed, in careless disregard of procedural requirements. The radiation levels inside the tank had not been predetermined and the individual was not in possession of radiation survey instrumentation to limit stay times, and licensee surveillance of this work activity was not being performed.

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As you are aware, procedural adherence in the area of radiation protection has been a continuing problem at Pilgrim over the last 18 months. In April 1984, a

$40,000 civil penalty was issued, and in November 1984, an Order Modifying License was issued, for two separate incidents involving a substantial potential for an exposure in excess of the regulatory limit because of a failure to follow procedures. In your response to the second incident, you appropriately concluded that the cause was not only a failure to follow procedures but failure to pro-vide adequate oversight to ensure procedural adherence. This latest incident, which includes additional examples of failure to adhere to procedures, further demonstrates the need for improved oversight of radiation protection activities.

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Boston Edison Company JUN 2 61985

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M/C Nuclear 2 We emphasize that licensees are not only responsible for development of a satisfactory radiation protection program, establishment of adequate procedures to implement the program, and training of personnel in expected performance, but are also responsible for maintaining adequate oversight of employee and contractor activities and control of this program and those of their con-tractors to assure adherence to program requirements , identification of devi-ations, and the implementation of prompt corrective actions to resolve identi-fied problems and to prevent recurrence.

In addition to the multiple examples of failure to follow procedures specified in Item A, one of the violations, Item B, involved failure to establish a proce-dure describing how to use a remote reading teledosimetry system to perform radiological monitoring of personnel working in high radiation areas. Such procedures, required by the Technical Specifications, are normally established to meet the procedure establishment requirements of Regulatory Guide 1.33 which is incorporated by reference into your Technical Specifications and would normally contain guidance as to: (1) maximum whole body radiation dose rates such a system could be used in; (2) allowable dose rate gradients the system can be used in; (3) proper positioning of the teledosimeter on an individual; (4) frequency of checking dose accumulation of the system; (5) methods of periodically verifying proper operation of the system while it is being used; (6), allowable accumulated exposure an individual could accumulate using the system as the primary real-time monitoring device and; (7) acceptable methods for notifying an individual wearing a teledosimeter that he has received his allowable exposure and is required to exit the high radiation area. This latter item is particularly important because the teledosimetry device used by Boston Edison was not an alarming dosimeter. An alarming dosimeter was required by your Technical Specifications.

At the time of this event, Boston Edison had in place a procedure which clearly described methodology for performing radiation monitoring in high radiation areas. Your procedures required that this monitoring be performed by a radio-logical controls technician with a survey meter at a frequency specified on the Radiation Work Permit. No other procedures were established which described an alternate methodology for performing monitoring of personnel working in high

radiation areas.

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Our review of the circumstances surrounding Item B found that a contractor

Radiological Controls Supervisor elected, on his own initiative, to eliminate the procedurally described high radiation area monitoring requirements incor-

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porated into the RWP used for sludge lancing, and use an alternate methodology (i.e. the teledosimetry system). This action by the contractor supervisor reduced the quality of the high radiation area controls established for sludge lancing because: (1) although a procedure was in place which described set-up of the teledosimetry system, no procedure guidance was in place explaining how to use the device for actual monitoring of personnel working in high radiation areas, and (2) periodic visual oversight of an individual working independently

, in a high radiation area was no longer being performed.

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OFFICIAL RECORD COPY CP PKG PILGRIM - 0001.0.1 06/25/85

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• ' Boston Edison Company

• ' JUN 2 61985 M/C Nuclear 3 The violations discussed above, some of which occurred over several days, demonstrate that at the time of the incident, both workers and supervisors violated radiological control program procedure requirements and no effective management control system was in place to readily identify these violations and initiate appropriate, timely, and comprehensive corrective action. These items further demonstrate the importance of improved oversight of radiation protection activities.

If you have any additional questions or comments, please contact me. No reply to this letter is required. Your cooperation with us is appreciated.

Sincerely, Origi'nal signed by Tho=as E. Murley Thomas E. Murley Regional Administrator CC:

A. V. Morisi, Manager, Nuclear Management Services Department C. J. Mathis, Station Manager Joanne Shotwell, Assistant Attorney General Paul Levy, Chairman, Department of Public Utilities W. J. Nolan, Chairman, Plymouth Board of Selectmen Plymouth Civil Defense Director Senator Edward P. Kirby Public Document Room (PDR)

Local Public Document Room (LPDR)

Nuclear Safety Information Center (NSIC)

NRC Resident Inspector Commonwealth of Massachusetts (2)

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BDBTON EDISON COMPANV Ea!Etif tst Orricts too Sortstow StacEr BOSTQh,M AssACHUEETTS 07199 STEPHEN J SWECNEY pat &tDTNT Cseirr sat ufws OFFICf's April 5,1985 BEco. Ltr. #65-068 Dr. Thomas E. Murley Regional Administrator U.S. Nuclear Regulatory Commission Region I 631 Park Avenue King of Prussia, PA. 19406 License No. DPR-35 Docket No. 50-293 Re: Notice of Violation INRC InsDection Nos. 50-293/B4-44 and 85-02 )

Dear Dr. Marley:

This letter is in response to the above Notice of Violation concerning a radiological incident which occurred at Pilgrim Station on December 17, 1984.

The Notice of Violation was communicated to Boston Edison Company with your letter dated March 6,1985.

j Boston Edison's detailed response to the Notice of Violation is contained in f the Attachment to this letter. As President and Chief Executive Officer I want to assure you that Boston Edison acknowledges the seriousness of the incident giving rise to the Notice of Violation andAt is the firmly committed same time, as to maintaining a strong radiological safety program.

amplified in the Attachment, we believe that the circumstances surrounding the violation make the categorization of the violation as Severity Level III_

inappropriate._and we therefore respectfully request that you consider assigning these violations to a lower Severity Level. We stress that the "C" primary cause of the major incident involving the individual entering the

! monitor tank without proper authorization was the willful disregard of j

instructions by that individual.

In addition, Boston Edison wishes to take exception to the statement contained in your letter that lack of_ adequate health physics management oversig~ht the crimarv cause of the incident.

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' ' human and financial resources to developing and implementing an extensive multi-deparunental Radiological Improvement Program (RIP) to address previously identified programmatic deficiencies on a long-term basis prior to Until full implementation of the RIP can be achieved, an

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the end of 1985.

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Dr. Thomas E. Murley

. Aprl) 5, 1985 Page Two Interim Program (IP) has been initiated to strengthen radiological controls in the interim period. The decision to make such extensive comitments was made_

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prior to the "C" monitor tank incident. J e beTreV rthit osr long term comitments as evidenced in the RIP as well as the corrective and preventive

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measures discussed in the Attachment which were enacted imediately following the "C" nonitor tank incident reflect the seriousness of Boston Edison's consnitment to radiation safety.

Should you have any questions or concerns regarding this response, please do not hasitate to call upon either myself or Mr. Harrington, our Senior Vice President - Nuclear.

Very truly yours, i ,

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Comonwealth of Massachusetts County of Suffolk Then personally appeared before me Stephen J. Sweeney who, being duly sworn, did state that he is President and Chief Executive Officer of the Boston Edison Company, the applicant herein, and that he is duly authorized to execute and file the submittal contained herein in the name and on behalf of the Boston Edison Company and that the statements in said submittal are true to the best of his knowledge and belief.

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ATTACHMENT , Page 1 of 4

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!htsponse to Notice of Violation ~

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(NRC InsDection Mos. 50-293/84-44 and 85-02)

Notice of Violation "A" ,2 Technical Specification 6.11 requires that radiation protection procedures be adhered to for all operations involving personnel radiation exposure.

Precedure 6.1-022, " Radiation Work Femits (RWP)," states in Section V. A.

that it is the responsibility of the first~line supervisor and the individuals working for the supervisor under the control of an RWP to follow all instructions on the RWP.

Procedure 6.1-022, also states in Section C.7 that all RWPs for work in high radiation areas must specify constant or periodic surveillance and that the surveillance frequency must be specified on the RWP. This surveillance is to be perfomed by a technician with a survey meter.

Procedure 6.1-022, states in section c.10 that an RWP revision sheet be .

completed if for any reason it becomes necessary to change RWP requirements or instructions, m

Contrary to the above:

1. On December 17, 1984, certain instructions specified in RWP No.

B4-3057, dated November 19, 1984, were not followed, as evidenced below; a. RWP Ho. 84-3057, prohibited entry into the 'C' Monitor Tank without HP supervisory approval.

~ However, at about 2:00 p.m., an individual who perfomed work under RWP 84-3057 entered the 'C' Monitor Tank without HP supervisory approval.

I b. RWP Ho. 84-3057 specified the perfomance of high radiation area surveillance at a frequency of every half-hour.

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However, between 10:00 a.m. and 3:20 p.m., no high radiation area surveillance by a technician with a survey rneter was perfomed.

c. RWP Ho. S4-3057 also required that a breathir.g zone air (BIA)

sampler be provided to each person during sluege-lancing operation.

However, between 2:30 p.m. and 3:20 p.m., an individual perfomed sludge-lancing of the 'C' monitor tank under the coverage of RWP Ho. 84-3057, and no BIA was provided to the individual, nor were other air samplers present in the area.

2. On or about December 14, 1984, a change was made to RWP No. 84-3057 deleting the need to perform periodic surveys every one-half hour in the area of the monitor tanks, and a revision sheet showing the change was not cocpleted. The RWP was used for several days to provide radiological controls for sludge-lancing of the 'C' monitor tank, and the surveys specified in the RWP were not trade.

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ATTACHMENT Page 2 of 4

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. ' Resconse to Violation "A" Boston Edison believes that Violatlon "A" should be considered in two separate parts: Item 1.a which directly involved the unauthorized entry of the individual into the 'C" monitor tank and Items 1.b,1.c and 2 which involved failures to follow proper procedures with respect to Radiation Work Permits. With respect to Item 1.4 the seriousness of the incident is acknowledged, but it is not clear what Boston Edison could have done to prevent the incident. We do not believe therefore that Item 1.a should be considered a violation, or in any event, we do not believe it should be categorized as a violation of Severity level III categorization. With respect to the remaining items we admit that these were indeed violations, however we do not believe that they Were by themselves of Severity Level III category. In each of Item 1.b, 1.c and 2 the specific change to the RWP would have been acceptable, if properly made. Thus, although it is clear tL.r. proper procedures should have been folicwed and the RWP should have been evised in writing rather than orally, we do not believe that

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there was ever a " substantial potential for an exposure or release in excess of 10 CFR 20" from the improper oral amendments to the RWP in ,

question. Consequently, we respectfully request a lower categorization of Severity Level for the subject incident. Following is specific infomation on the causes of each item and the correction actions which have been taken or are planned:

It has been established that in the case of Item la, the contractor

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employee who entered the tank was fully aware that he was not allowed to do so by procedure. However, he took deliberate actions, such as removing his headset and teledosimetry, 50 that the health physics technicians and the foreman who were monitoring him from outside the area would not know he was entering the tank.

In response to items 1.b end 2, health physics technicians discontinued the periodic surveillances required by the RWP based upon verbal instructions from a contra: tor Radiological Group supervisor. Tne supervisor perceived use of the teledosilretry system as the equivalent of perforcing the surveillances. Due to administrative oversight, the I contractor supervisor neither infomed Boston Edison Radiological Group i supervision of this change, nor did be revise the RWP appropriately.

Concerning item 1.c, a breathing zone air sar.pler was not provided to the individuals perfoming sludge-lancing because the health physics i technician on duty concluded that an air sampler was not necessary based l upon the type of wark being perfomed and en the results of an air sample ;

collected that morning during the perfomance of similar work. This

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decision was also discussed with and verbally approved by the contractor Radiological Group supervisor. Due to administrative oversight, the RWP was not appropriately revised.

After being informed of the incident on December 17, 1994, Boston Edison

! management inrediately suspended monitor tank desludging work and initiated an investigation into the circumstances surrounding the l

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incident. Subsequently, the individual who willfully violated the RWP and

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the procedure by entering the tank had his employment terminated at

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Pilgrim Station. Additionally, two television _ cameras were installed in the monitor tank area allowino constant visual surveillance of the

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oTerret4ertTThe Ndfation protecfien technicians stationed outside th^e

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Boston Edison and contractor techni'cians were reinstructed verbally and in writing of the importance of following procedures and the consequences of failing to do so. Also, the contractor Radiological Group supervisor and four contractor technicians involved in the incident were given written reprier. ands. Other individuals working on the desludging operation were also reinstructed on the procedures to be followed during this project.

Finally, the remainder of the monitor tank desludging was perfomed under the purview of Boston Edison (rather than contractor) Radiological Group supervisors and technicians. .

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Full compliance with respect to ,1.hese piolations w a achieved pricr to the resumption of work on the "C" monitoritank on 1/8/8S. -

BostonEdisonhaslessenedthe.discrefianaryauthorityallowedcontractor '

health physics personnel by revising the Station procedure governing Radiation Work Permits so that only Boston Edison supervisory personnel are permitted to revise the requirements of a Radiation Work Permit.

Additionally, the Vice President-Nuclear Operations reinforced, via memorandum to Station personnel, the policy that failure to follow procedures would not be tolerated by Boston Edison. Finally, it should be noted that on January 17, 1985, an Internal Review Program of work in progress was initiated with the use of an independent auditor.

In addition to the preceding corrective actions we would also point out that Boston Edison has undertaken an extensive Radiological Improvement Program (RIP) to address programatic deficiencies on a long-tem basis.

Included within RIP is a complete analysis, and overhaul where necessary, of Radiation Work Fermits and the controlling procedure. Upon completion of the RIP at the end of 1985 Boston Edison would expect to have impleeented a comprehensive approach to assuring that all RWP-controlled work is conducted in a safe manner.

Notice of Violation "B" Technical Specification 6.8 requires that procedures be established, implemented, and maintained that meet or exceed the requirements of Appendix "A" of USHRC Regulatory Guide 1.33, November 1972. This

! Regulatory Guide recomends in Appendix A, Section 6.5, that procedures for restrictions and activities in High Radiaticn Areas and for surveys and monitoring be established.

Contrary to the above, on December 17, 1984, a remote reading teledosimetry system was used for purposes of surveying, monitoring, and restricting activities during sludge-lancing of the 'C' monitor tank, and no procedures detailing use of this device for this purpose had been established.

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- .Resconse to Violation "B" The RWP controlling the job required high radiation area surveillances at half-hour intervals. As noted in cur response to Violation "A" above, the surveillances were discontinued when a contractor Radiological Group supervisor infomed the health physics technician covering the job that using the teledosimetry system was equivalent. The contractor supervisor failed to inform Boston Edison supervision of his actions and also failed to appropriately revise the RWP to adFess use of the teledosimetry for this purpose. Note that a Station fOcedure governing teladosimetry usage existed at t59 time of the incident ' Boston Edison admits that the job-specific RWP should have refere ced this procedure if the teledosimetry was to to used in this manner. However, we stress that this violation does not represent a f ai/ure to establish procedures as required by the Technical Specification and Regulatory Guide 1.33 which you cited.

As with Violation "A", although i is edmitted that there"B" was a violation should not of proper RWP procedure, it is s itted that Violation have been characterized as Sever y Leyl III because there was not a '

substantial potential for an exposcr4}r release in excess of 10 CFR 20". As with Violation "A" we Qeref respectfully request a lower categoritationofSeverityLeveffort, subject incident. c

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As noted in our response to ViglationhA", upon being infomed of the the desludging operations monitortankincident.BostonjlEdisonsuspendedto investigate the situatio being used in lieu of performing the required surveillances, Boston Edison issued supervision instructions to cease this practice. Additionally, as noted earlier, the contractor supervisor received a written reprimand and Station personnel were inforced by memorandum from the Vice President-Nuclear Operations that failure to folicw procedures would not be tolerated.

Full compliance was achieved prior to recommencement of the work on 1/8/85 when the use of the teledesimetry system in lieu of perfoming the required surveillances was discontinued.

As noted earlier in this response, the Station procedure governing RWP's

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' has been revised to restrict - to Boston Edison supervisory personnel alone - the authority to revise RWP requirements. Also, as discussed above, an Internal Review Program has been initiated, providing Boston Edisen Radiological Group management with an additional means of assuring adherence to procedures. In acdition, and as further corrective action,

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we would again point to the Radiological Improvement Program (RIP) which Boston Edison is in the process of implementing and which we believe will

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ccnstitute an effective icng-range approach to problems in the radiological safety area.

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