On October 13, 2016, several
ARMs unexpectedly alarmed when six filters were simultaneously lifted from the
SFP to be placed into a radioactive waste liner . The radiation work permit (
RWP) governing performance of the job,
RWP 3003788, Revision 00, dated September 7, 2016, had the following , Hold Point , requirements in the event that unexpected radiological conditions occurred during the movement of spent filters: Stop work immediately and notify
RP personnel if an unanticipated
ARM alarms. If a reading greater than 10 rem/hour contact or 800 millirem/hour at 30 centimeters was detected, but not expected, place the filter back into the
SFP . The six filters that had been raised from the
SFP had radiation levels as high as 14,000 rem/hour on contact and over 300 rem/hour at almost 30 centimeters. However, the filters were placed in the liner rather than back into the
SFP , as specified in the
RWP and instructed by
RP staff during the evolution.
Technical Specification 5.4.1.a requires, in part, that procedures be written, implemented, and established for those areas recommended in
Regulatory Guide 1.33, Appendix A, Revision 2, 1978. Section 7(e) of Appendix A recommends written procedures for
RWP systems to control access to radioactive materials and limit personnel exposure. Radiation Work Permit 3003788 stated, in part, in the event of unexpected radiological conditions during movement of spent filters, stop work immediately if an unanticipated area radiation monitor alarms, and if a reading greater than 10 rem/hour contact was detected but not expected, place the filter back into the
SFP. Contrary to the above, on October 13, 2016 , the licensee f ailed to stop work immediately when several area radiation monitors unexpectedly alarmed and failed to place the filters back into the
SFP when readings greater than 10 rem/hour contact were detected but not expected . Subsequently, 16 workers received an addition al 63.5 millirem when the instructions of the
RWP and
RP staff were not followed. The finding was of very low safety significance (Green) because it did not involve: (1) as-low- as-reasonably achievable (
ALARA) planning and controls ; (2) a radiological
overexposure; (3) a substantial potential for an exposure; or (4) a compromised ability to assess the dose. This issue was entered into the licensees corrective action program as
ARs 356390 and 358265.
