Information Notice 1986-44, Failure to Follow Procedures When Working in High Radiation Areas

Failure to Follow Procedures When Working in High Radiation Areas

ML031250056
Person / Time
Site:	Beaver Valley, Millstone, Hatch, Monticello, Calvert Cliffs, Dresden, Davis Besse, Peach Bottom, Browns Ferry, Salem, Oconee, Mcguire, Nine Mile Point, Palisades, Palo Verde, Perry, Indian Point, Fermi, Kewaunee, Catawba, Harris, Wolf Creek, Saint Lucie, Point Beach, Oyster Creek, Watts Bar, Hope Creek, Grand Gulf, Cooper, Sequoyah, Byron, Pilgrim, Arkansas Nuclear, Three Mile Island, Braidwood, Susquehanna, Summer, Prairie Island, Columbia, Seabrook, Brunswick, Surry, Limerick, North Anna, Turkey Point, River Bend, Vermont Yankee, Crystal River, Haddam Neck, Ginna, Diablo Canyon, Callaway, Vogtle, Waterford, Duane Arnold, Farley, Robinson, Clinton, South Texas, San Onofre, Cook, Comanche Peak, Yankee Rowe, Maine Yankee, Quad Cities, Humboldt Bay, La Crosse, Big Rock Point, Rancho Seco, Zion, Midland, Bellefonte, Fort Calhoun, FitzPatrick, McGuire, LaSalle, 05000000, Zimmer, Fort Saint Vrain, Shoreham, Satsop, Trojan, Atlantic Nuclear Power Plant, Skagit, Marble Hill
Issue date:	06/10/1986
From:	Jordan E L NRC/IE
To:
References
IN-86-044, NUDOCS 8606040010
Download: ML031250056 (5)

LIS ORIGINAL SSINS No.: 6835IN 86-44UNITED STATESNUCLEAR REGULATORY COMMISSIONOFFICE OF INSPECTION AND ENFORCEMENTWASHINGTON, D.C. 20555June 10, 1986IE INFORMATION NOTICE NO. 86-44: FAILURE TO FOLLOW PROCEDURES WHEN WORKINGIN HIGH RADIATION AREAS

Addressees

All nuclear power reactor facilities holding an operating license (OL) or aconstruction permit (CP) and research and test reactors.

Purpose

This information notice is provided to alert licensees of the problem ofrecurring, unauthorized entries by maintenance workers into high radiationareas. A recent event is discussed below, and a related event is summarized inAttachment 1. Since the workers ignored and bypassed maintenance proceduresthat include radiological controls established to limit exposures in highradiation areas, it is fortuitous that during these entries no personnelexposure limits were exceeded.It is expected that recipients will review this notice for applicability totheir facilities' work controls programs and consider actions, if appropriate,to preclude the occurrence of a similar problem at their facilities. Sugges-tions contained in this information notice do not constitute NRC requirementsand, therefore, no specific action or written response is required.Past Related Correspondence:INPO Significant Event Report (SER) 50-85, "Uncontrolled Personnel RadiationExposure," November 4, 1985 (discusses two events).INPO Significant Operating Experience Report (SOER) 85-3, "Excessive PersonnelRadiation Exposures," April 30, 1985 (discusses seven events).IE Information Notice No. 84-19, "Two Events Involving Unauthorized EntriesInto PWR Reactor Cavities," March 21, 1984.IE Information Notice No. 84-59, "Deliberate Circumventing of Station HealthPhysics Procedures," August 6, 1984 (discusses six events).8606040010 IN 86-44June 10, 1986

Description of Circumstances

On January 8, 1986, at Turkey Point, an instrument and controls (IC) technicianmade an unaccompanied, unauthorized entry into a high radiation area to com-plete repairs on the traversing incore probe (TIP) drive unit with an irradi-ated TIP withdrawn into the work area. Earlier that same day, with a healthphysics (HP) technician providing job coverage, the IC technician had madeadjustments to the TIP drive unit (dose rates only 5 to 25 mR/hr), which laterenabled the technician to successfully withdraw the TIP into the accessible TIPdrive work area.During the unauthorized entry, the IC technician received 500 millirem wholebody exposure during an approximately 5-minute stay time in a work area, whichwas later calculated to be 6 R/hr in the general area. The radiation level 1foot away from the work area was 65-70 R/hr on contact with the tubing contain-ing the irradiated TIP. The low-range Geiger-Mueller (GM) portable surveyinstrument (scale of 0-1 R/hr) used by the IC technician upon entering the highradiation area initially moved up the scale to 800 mR/hr and then reportedlywent rapidly down the scale to zero, when moved closer the the radiationsource. The IC technician failed to recognize the malfunctioning surveyinstrument and stayed in the area to complete his maintenance task. At thesedose rates, it was fortuitous that the technician did not remain in the TIParea for any longer period.Subsequent licensee and NRC regional review of the event revealed several keyfactors that contributed to the incident.1. Failure To Follow ProceduresNumerous procedural violations occurred before and during the unauthorizedentry. These violations included failure to notify HP personnel beforeoperating the TIP, performing craft work outside the scope of the author-ized plant work order (PWO), and making entry and working alone on the TIPsystem.2. Personnel ShortcomingsThe IC technician's foreman failed to clearly define the TIP system problemand provide adequate instructions on the PWO. The IC technician failed toobey the local radiological area warning, a posting that read "highradiation area -keep out." Inadequate training caused the IC technicianto fail to recognize a malfunctioning survey instrument (downscale readingcaused by GM detector tube continuous discharge response to intenseradiation levels), which he was using to help control his exposure.The NRC noted subsequent to the event that, although not contributory to thisincident, governing maintenance procedures for the TIP system did not requiretagging out of other operable TIPs (to prevent inadvertent withdrawal into anoccupied work area) with work in progress on a malfunctioning TIP unit. Forfuture TIP work, the licensee agreed to control movement of the irradiated TIPswith equipment tag out control IN 86-44June 10, 1986 Discussion:The NRC continues to note repeated occurrences of unauthorized entries intohigh radiation areas (see Past Related Correspondence). In most of the indi-vidual events discussed in these documents and the two events in this notice,failure of personnel to adhere to existing work/control procedures or radiationwork permits (RWP), or both, is a central cause of the exposure incidents.Adherence to work/surveillance procedures forms a basic framework for providingeffective, consistent radiological controls for work in high radiation areas.Short of providing direct, continuous health physics coverage for each andevery task, these procedures serve as the formal mechanism for initiatingnecessary communications between various plant worker crafts groups and thehealth physics support group. This communication results in appropriateradiological support (e.g., RWP issuance) for the maintenance/surveillanceactivities. Bypassing these procedures and thus failing to comply with theradiological precautions in them seriously weakens the health physics controlprogram established to protect the workers. It is the licensee's responsibil-ity to ensure that these procedures are adhered to.To emphasize the importance of workers properly performing work activities inhigh radiation areas, appropriate enforcement action has been proposed for theTurkey Point event (proposed $50,000 civil penalty).No specific action or written response is required by this information notice.If you have any questions about this matter, please contact the RegionalAdministrator of the appropriate regional office or this office.dwari o Jor , D irectorDivision of Emergency Preparednessand Engineering ResponseOffice of Inspection and EnforcementTechnical Contacts: James E. Wigginton, IE(301) 492-4967Roger L. Pedersen, IE(301) 492-9425

Attachments:

1. Related Exposure Event2. List of Recently Issued IE Information Notices Attachment 1IN 86-44June 10, 1986 RELATED EVENT SUMMARYAt the Cooper Nuclear Station on August 28, 1985, two IC technicians performedmaintenance (TIP alignment) as required by a craft work procedure. Contrary tothe work procedure's radiological-cautions warnings, these workers failed toobtain a special RWP and entered the TIP drive enclosure housing, ignoring theaccess posting, "Notify Health Physics Prior to Opening." The TIP maintenanceprocedure further warned that the drive unit's Gleason reel is spring loadedand the incore detector could be withdrawn by the spring tension. It furtherwarned that the withdrawn incore detector probe could be highly radioactive.Upon opening the unsurveyed enclosure, they found the TIP had withdrawn intothe enclosure and the detector had broken off. The technicians immediatelyexited the high radiation and high airborne radioactivity area. The indivi-duals each received approximately 200 mrem whole body exposure and airborneintakes of 44 and 90 MPC-hrs.As corrective actions, the licensee (1) stressed to all station personnel theimportance of properly following radiological controls and (2) revised thegoverning maintenance procedure to require written documentation (signoff)notifying HP before working on the TIP syste Attachment 2IN 86-44June 10, 1986LIST OF RECENTLY ISSUEDIE INFORMATION NOTICESInformation Date ofNotice No. Subject Issue Issued to86-43ProblemsSamplingiodineWith Silver ZeoliteOf Airborne Radio-86-42Improper MaintenanceRadiation MonitoringOfSystems86-4186-32Sup. 186-4086-3986-38Evaluation Of QuestionableExposure Readings Of LicenseePersonnel DosimetersRequest For Collection OfLicensee RadioactivityMeasurements Attributed toThe Chernobyl Nuclear PlantAccidentDegraded Ability To IsolateThe Reactor Coolant SystemFrom Low-Pressure CoolantSystems in BWRSFailures Of RHR Pump MotorsAnd Pump InternalsDeficient Operator ActionsFollowing Dual Function ValveFailuresDegradation Of StationBatteriesChange In NRC PracticeRegarding Issuance OfConfirming Letters ToPrincipal Contractors6/10/866/9/866/9/866/6/866/5/865/20/865/20/865/16/865/16/86-All power reactorfacilities holdingan OL or CPAll power rectorfacilities holdingan OL or CPAll byproductmaterial licenseesAll power reactorfacilities holdingan OL or CPAll power reactorfacilities holdingan OL or CPAll power reactorfacilities holdingan OL or CPAll power reactorfacilities holdingan OL or CPAll power reactorfacilities holdingan OL or CPAll power reactorfacilities holdingan OL or CP86-3786-36OL = Operating LicenseCP = Construction Permit