IR 05000373/1998020

Insp Repts 50-373/98-20 & 50-374/98-20 on 980812-13. Non-cited Violation Noted.Major Areas Inspected: Circumstances Surrounding 980723 Incident Re Transfer of Radioactive Samples from Storage Areas on Refuel Floor

ML20151V175
Person / Time
Site:	LaSalle
Issue date:	09/08/1998
From:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20151V169	List: IR 05000364/1998020 IR 05000373/1998020
References
50-373-98-20, 50-374-98-20, NUDOCS 9809140137
Download: ML20151V175 (12)

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U.S. NUCLEAR REGULATORY COMMISSION REGIONlli Docket Nos:

50-373;50-374 License Nos:

NPF-11; NPF-18 i

l Report Nos:

50-373/98020(DRS); 50-374/98020(DRS)

i Licensee:

Commonwealth Edison Company Facility:

LaSalle Nuclear Generating Station, Units 1 and 2 Location:

2605 N. 21st Road

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Marseilles, Illinois 51341-9756

Dates:

August 12-13,1998 Inspector:

W. Slawinski, Senior Radiation Specialist Approved by:

G. L. Shear, Chief, Plant Support Branch 2

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Division of Reactor Safety

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EXECUTIVE SUMMARY LaSalle Nuclear Generating Station, Units 1 and 2 NRC Inspection Reports 50-373/98020; 50-374/98020 This announced, special inspection was conducted to review the circumstances surrounding a July 23,1998 incident, involving the transfer of radioactive samples from a storage area on the refuel floor to the radioactive waste truck bay. This report covers a two day site inspection concluding on August 13,1998, performed by a regional Senior Radiation Specialist.

Plant Sucoort The licensee's investigation of a July 23,1998 incident involving the transfer of

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i radioactive samples from the refuel floor was timely and thorough, and corrective

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actions were adequate to address the apparent causes. No significant radiological consequences resulted from the incident; however, worker judgement was poor because work was conducted outside the known scope of the as-low-as-is-reasonably-achievable (ALARA) plan, and continued even though the electronic dosimetry worn by the workers alarmed on several instances and other radiological problems occurred a

during the course of the work. Although the radiological work conditions were continually monitored by a radiation protection technician and job coverage was i

adequate to prevent an exposure in excess of regulatory limits, the problems with job l

planning and procedural adherence placed workers at increased radiological risk. A i

non-cited violation was identified (Section R1.1).

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Report Details IV. Plant Support R1 Radiological Protection and Chemistry (RP&C) Controls R1.1 Problems During Transfer of Radioactive Samoles a.

Insoection Scoce (IP 837.5Q)

The inspector reviewed the circumstances surrounding a July 23,1998 incident, involving the transfer of radioactive samples from a storage area on the refuel floor to the radioactive waste (radwaste) truck bay. The inspector interviewed plant staff involved in the incident and its follow up investigation, reviewed the licensee's investigation report, and reviewed the radiation work permit (RWP), the as-low-as-is-reasonably-achievable (ALARA) plan and associated documents and procedures.

b.

Observations and Findinas (1)

Background Information In mid-1996, the licensee collected samples from spent fuel bundles for offsite analysis by the fuel vendor, as part of an effort to evaluate the effectiveness of the zine injection program. The samples were composed of fuel bundle scrapings collected on filter papers, and housed in small (scintillation cocktail j

sized) vials. Several unsatisfactory samples were not shipped for vendor analysis, and were bagged and stored in a shielded container or the refuel floor,

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where they remained for over two years. Contact dose rates on the samples

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were believed to exceed 1 rad / hour, and their form was expected to be solid and not readily dispersible.

101998, the licensee initiated a program to reduce the number of radiologically controlled areas on the refuel floor. As part of this program, the licensee

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planned to transfer the stored samples along with a small volume of dry active waste to the radwaste truck bay, for packaging and subsequent shipment to a Iow level waste burial site.

(2)

Job Plannina and Scheduling Job coordination involved the station fuel handler, radiation protection and radwaste groups, the latter two supporting the former. On or about July 15, 1998, the radwaste staff notified the fuel handler group that a cask (high integrity container) was available for shipment of the samples to a burial site.

The fuel handling supervisor, however, did not notify and seek assistance from j

the radiation protection (RP) ALARA group until July 21,1998, leaving little time to develop an RWP and ALARA plan since the job was scheduled to begin the

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next day. The job was later rescheduled for July 23,1998, due to problems in the radwaste truck bay.

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On July 22,1998, an ALARA plan was developed by the station's ALARA analyst

with assistance from the fuel handling supervisor, who determined that the work

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could be conducted under an existing RWP that was routinely used by the fuel handlers. That RWP encompassed fuel handling, housekeeping, decontamination, and minor maintenance activities on the refuel floor. The

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electronic dosimetry (ED) dose rate alarm setting established by the existing RWP was 100 millirem / hour, a value later determined by the licensee's investigation to be too low for the job. The alarm setting was not based on radiological survey data specific to the job, as required by licensee procedure.

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The inspector evaluated the ALARA plan, discussed its development with RP

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management and staff, and concluded that the plan was not adequately developed. (The ALARA analyst that prepared the olan could not be interviewed by the inspector because the individual's employment was terminated by the licensee shortly after the incident). Specifically, both RP management and the inspector agreed that the ALARA plan contained insuflicient radiological information about the samples, the plan failed to indica'e the number of samples or describe their packaging, and the plan did not include contingencies should the work plan fail or if problems occurred. Although the M ARA plan !.idicated

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that the contact dose rate on the samples (s) collective y was 20 redihour, that

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L information was reportedly based on an individual's recollection from 1996, when L

the samples were collected. A more recent survey of the samples was not

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performed, the survey information from 1996 was not confirmed or additional information sought, and a walkdown of the job site was not made to ensure that

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the equipment intended for the job was appropriate. Additionally, the ALARA plan was not documented on the licensee's standardized "ALARA Plan" form or

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similar record, and the plan did not include all the information normally

- documented in the licensee's ALARA plans. For example, the ALARA plan did j

not indicate if lessons leamed were incorporated in the job, did not specify if the

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plan was based on estimated dose rates, and failed to indicate if contingency plans were applicable, or provide other information relevant to the successful

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completion of the job. Since the ALARA analyst was unavailable for interview, it i

is not known why current radiological data or additional historical data and other

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usefulinformation conceming the ss mples was not obtained or confirmed. The licensee speculated that time conc! Jints impacted the develor ment of the ALARA plan, and the decision to use an existing RWP.

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(3)

- ALARA Plan Imolementation and Dose Controls

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The ALARA plan required that " reach tools' be used during removal of the samples from the shielded storage container, during placement of the samples

into a 3-inch by 12-inch tube, and during transfer of the tube (using an attached

rope) onto a cart for transport to the radwaste area. The tube was to be shielded f

with lead blankets, after its placement on the cart. The ALARA plan indicated i

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that "no direct contact of samples should be made." It was intended that a 4-foot long pole equipped with finger-type pinchers, a tool routinely used by the fuel handlers, be used as the reach tool.

Just prior to job commencement on July 23,1998, a pre-job brief was held by the ALARA analyst with the crew and supervisory staff involved in the work.

Attendance at the briefing included the two fuel handlers that were involved in the transfer of the samples from the refuel floor, and a radiation protection technician (RPT) that provided continuous job coverage. The two fuel handlers and RPT indicated to the inspector that the use of the reach tools was stressed during the briefing. However, one of the fuel handlers indicated that he questioned the necessity of the tools, since he handled the samples without tools in 1996, when they were originally placed in tha storage container. Although the 20 radihour maximum expected sample dose rate was mentioned at the pre-job briefing, the work crew indicated that the ED alarm settings were not discussed, nor was the number of samples or their packaging. While one of the fuel handlers recalled that the shielded container housed several small samples within a plastic bag, the RPT anticipated a single sample vial laying loose in the storage containct.

While preparing for the jub at the job site, the RPT and one of the fuel handlers determined that the reach tool could not be effectively used due to the storage container's small diameter well in relation to the size of the tool's fingers, and because there was not adequate clearance in the work area to manipulate the reach tool. The work area was located in the back comer of the refuel floor behind an elevator, an area that the inspector observed to be dimly lit and cramped. The fuel handler removed the bag that contained the samples from the storage container by hand, despite requirements to the contrary in the ALARA plan because: (1) the work crew reasoned that the samples could quickly and efficiently be removed by hand; (2) the fuel handler previously handled the samples without tools in 1996; and (3) the RPT was confident that the job could be conducted with little dose expended, based on the dose rate

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l measured at the mouth of the container's storage well after the lid was removed.

The dose rate measured by the RPT in the storage well was less than the 20 rad / hour value specified in the Al. ARA plan, j

As the fuel handler attempted to force the bag into the 3-inch diameter tube by hand, the worker's ED alarmed, indicating a dose rate greater than 100 millirem / hour. However, the work continued until the bag opened and some of the sample vials fell to the floor. During the attempted transfer of the bag into the tube, the dose rate at the fuel handlers chest was measured by the RPT at 500 millirem / hour. At this time, the RPT learned that the fuel handler's ED alarm was set at 100 millirem / hour, a value much lower than presumed by the RPT.

According to the RPT, radiation levels near the loose vials were about 1.5 rad / hour, after they fell to the floor. The workers left the area, regrouped, and decided to continue the job after a larger diameter tube was obtained by the other fuel handler supporting the job. One of the fuel handlers subsequently

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i retrieved the loose vials by hand, placed them into the larger tube, caped the tube and transferred it to the cart. The EDs worn by both fuel handlers momentarily alarmed while each placed lead blankets around the tube to shield the samples. The RPT measured 5 rad / hour on contact with the unshielded tube containing all the samples. A fourth, momentary ED dose rate alarm occurred fater, when one of the radwaste operators connected a sling to the unshielded

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' tube in preparation for its placement into the shipping cask.

The fuel handling supervisor was not present during the job, and later learned of the difficulties in completing the task. The ALARA analyst arrived on the refuel floor to observe the job while the lead blankets were being placed over the tube -

and the fuel handler's ED alarmed. The analyst then learned of the other problems that took place, and initiated a problem identification form (PlF). A Prompt investigation and Apparent Cause Evaluation (ACE) followed.

The highest dose rate measured by the fuel handler's ED was determined by the licensee to be 2.2 rad / hour, apparently while the lead blar'kets were placec over the tube that contained the samples. Emergency processing of the thermoluminescent dosimetry (TLD) worn by each fuel handler to monitor whole body dose and the extremity monitor worn by the individual handling the

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samples, showed maximum whole body and extremity doses of 56 millirem and

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105 millirem, respectively, for the July 1-23 period. Seventy three millirem was conservatively assigned as the deep dose equivalent for the maximally exposed worker, based on ED results for the period. The dose essigned to the RPT for the job was 10 millirem, also based on ED data. The inspector discussed dosimetry placement with the work crew and the RP staff, and agreed with the licensee's conclusion that the dosimetry provided an accumt? sssessment of the dose incurred by the workers.

The inspector determined that although the RPT allowed the crew to work outside the scope of the ALARA plan and handle the samples without the reach tool, the RPT was cognizant of the radiological conditions throughout the job and

adequately monitored the fuel handlers dose. No significant radiological

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consequences resulted from the incident; however, both the RPT and work crew demonstrated poor judgement in handling the samples without tools, and continuing to work despite ED alarms. Although RPT job coverage was l

adequate to prevent exposures from approaching regulatory limits, the

weaknesses in planning and implementing the job placed the work crew at increased radiological risk.

(4)

Procedure Adherence issues Several procedure adherence problems occurred during the job. These problems were identified in the licensee's prompt investigation and ACE, and further developed by the inspector during the inspection.

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Technical Specification 6.2.A(a) requires that applicable procedures recommended in Appendix A of Regulatory Guide 1.33. Revision 2, February

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1978, be established, implemented, and maintained. Appendix A of Regulatory Guide 1.33, Revision 2, February 1978, specifies in Section 7(e) that radiation protection procedures cover: (1) access control to radiation areas including a radiation work permit system; (2) personnel monitoring; and (3) implementation of ALARA program.

LaSalle Radiation Protection Procedure LRP-5824-10 (Rev 0), " Operation and Use of the Merlin Gerin Electronic Dosimeters," a procedure that implements the personnel monitoring program to satisfy Regulatory Guide 1.33, requires in Step F.2(a)(2) that the electronic dosimetry's dose rate alarm threshold be normally set at a level based on survey information for the job and, if applicable, historical information. However, as described in subsection (2) above, on July 23,1998, the dose rate alarms on the electronic dosimetry used by the fuel handlers were not set at a level based on survey information for the job, or based on historical Information.

LaSalle Administrative Procedure LAP-2200-7 (Rev 0), "ALARA Plan," a procedure that implements the ALARA program to satisfy Regulatory Guide

1.33, requires in Step D.1 that ALARA Plans be based on current radiological surveys of the actual work location or based on data obtained from similar jobs previously performed. Step F.13 requires that the ALARA plan be documented I

on Attachment A. "ALARA Plan," or that a computer generated plan with applicable information be completed. As described in subsection (2) above, on

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July 22,1998, the ALARA Plan was not based on current radiological surveys of the samples, or based on adequate historical survey data and other information necessary to properly handle the samples. Also, the ALARA Plan was not documented on Attachment A, or on a computer generated plan that included information equivalent to that specified on Attachment A.

LaSalle Administrative Procedure LAP-100-22 (Rev 21), " Radiation Work Permit Program," a procedure that implements the radiation work permit system to satisfy Regulatory Guide 1.33, requires in Step E.2.2 that the Job Supervisor ensure that workers in the work party perform the task in accordance with the provisions of the ALARA review. Step E.2.5 requires that the Radiation Protection Technician ensure that requirements from the ALARA review have been implemented and to contact radiation protection supervision if a conflict exists. Additionally, Step E.8 requires that radiation work permit pre-job briefings include, in part, a discussion of electronic dosimetry alarms, specifying the dose rate and accumulated dose alarm settings. At described in sub':ection (3)

above, on July 23,1998, neither the job supervisor or radiation protection technician that provided job coverage ensured that the requirements of the ALARA plan were implemented. Reach tools were not used as required by the plan, and workers had direct contact with the samples. Also, the radiation protection technician did not contact radiation protection supervision when a conflict' existed between the ALARA plan and the work activity. Additionally, the

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pre-job briefing conducted on July 23,1998, did not include a discussion of electronic dosimetry alarm settings. Had the dosimetry alarm setting; been discussed, their appropriateness may have been questioned, prompting further review of the job plan.

This non-repetitive licensee identified and corrected violation is being treated as a non-cited violation (NCV), consistent with Section Vll.B.1 of the NRC

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Enforcement Policy (NCV 50-373/98020-01; 50-374/98020-01).

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(5)

Licensee Corrective Actions The licensee's ACE attributed the apparent cause of the incident to the RPT's

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overconfidence. The RPTs decision to work outside the scope of the ALARA j

plan and continue despite ED alarms and other problems was based upon his job coverage experience, and the presumption that the job could be completed with less dose than if the job was stopped and resumed later. Contributing causes were the lack of proper job planning and scheduling and included an inadequately developed ALARA plan, and poor decisions by the RPT and work

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crew. Inspector interviews also disclosed that workers were confused prior to

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the incident regarding station management expectations for implementing

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ALARA plans, and about recent changes in RP work coverage philosophy.

Licensee con'ective actions included disciplinary action for the involved staff and review of the event with RP and feel handler groups. Additionally, management expectations regarding job coverage, ALARA plan development and

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implementation, and ED alarm response were discussed with RP staff and documented in RP shift standing orders. A PlF was initiated to track the job scheduling problem. These corrective actions appeared adequate.

c.

Conclusions The licensee's investigation of the incident was timely and thorough, and corrective actions were adequate to address the apparent causes. No significant radiological consequences resulted from the incident; however, the work crew's judgement was poor because work was conducted outside the known scope of the ALARA plan, and continued even though several raciological problems occurred during the course of the work. Although the radiological conditions were continually monitored by a RPT and job

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coverage was adequate to prevent an exposure in excess of regulatory limits, the problems with job planning and procedural adherence placed workers at increased radiological risk.

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V. Management Meetings

'X1 Exit Meeting Summary

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The inspector presented the inspection results tc members of licensee management at the conclusion of the inspection on August 13 1998. The licensee acknowledged the findings presented and identified no proprietary infermation.

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s PARTIAL LIST OF PERSONS CONTACTED P. Barnes, Restart Program Manager C. Berry, Chief of Staff F. Dacimo, Site Vice President T. Halliday, Assistant Health Physics Manager N. Hightower, Health Physics Manager C. Kelley, Lead Health Physicist, Operational P. Knoll, Root Cause Analyst D. Reif, Fuel Handling Supervisor B. Riffer, Quality and Station Assurance Manager INSPECTION PROCEDURES USED IP 83750 Occupational Radiation Exposure

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ITEMS OPENED AND CLOSED Ooened and Closed 50 373/98020-01 NCV Multi-procedure adherence problems involving the 50-374/98020-01 development and implementation of the ALARA plan, pre-job briefing discussion, and dose rate alarm set points.

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LIST OF ACRONYMS USED ACE-Apparent Cause Evaluation

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ALARA-As-Low-As-Reasonably-Achievable

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ED Electronic Dosimetry -

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NCV Non-Cited Violation

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' PIF Problem identification Form Radwaste Radioactive waste RP Radiation Protection

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-RPT'

Radiation Protection Technician

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RWP Radiation Work Permit TLD.

Thermoluminescent Dosimeter

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PARTIAL LIST OF DOCUMENTS REVIEWED Station Procedytes LRP 5000-07 (Rev 6)

Unescorted Access to and Conduct in Radiologically Posted Areas LRP 5824-10 (Rev 0)

Operation and Use of the Merlin Gerin Electronic Dosimeters LAP 100-22 (Rev 21)

Radiation work Permit Program LAP 2200-07 (Rev 0)

ALARA Plan RWPs and ALARA Plans RWP # 980192 (Rev 0)

Fuel Handling, Fuel Receipt, Housekeeping, Decontamination, Water Blasting, Minor Maintenance

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ALARA Plan (7/22/98)

Hi Rad Transfer From Refuel Floor to Radwaste Investiaation Reoorts and PlFs Prompt investigation Work Completed Outside the Scope of the RWP ALARA Plan (7/23/98)

Apparent Cause Evaluation Work Outside Original Scope of ALARA Plan and Attachments (8/11/98)

PIF # L1998-5370 (7/23/98) Work Outside Original Scope of ALARA Plan PIF # L1998-E637 (8/6/98)

Failure of Fuel Handling to Schedule High Risk Evolution PlF # L1998 3836 (5/22/98) Lack of Conservative Decision Making by RP Personnel 12