ML18095A822

LER 91-011-00:on 910220,high Rad Area Found Unlocked & Unguarded.Caused by Personnel Error.Event Reviewed by Radiation Protection Dept & Corrective Action Taken Against Technician responsible.W/910320 Ltr

ML18095A822
Person / Time
Site:	Salem
Issue date:	03/20/1991
From:	Labruna S, Pollack M Public Service Enterprise Group
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-91-011, LER-91-11, NUDOCS 9104010366
Download: ML18095A822 (4)

Text

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Public Service Electric and Gas Company P.O. Box 236 Hancocks Bridge, New Jersey 08038 Salem Generating Station March 20, 1991 U. S. Nuclear Regulatory Commission Document Control Desk Washington, DC 20555

Dear Sir:

SALEM GENERATING STATION LICENSE NO. DPR-70 DOCKET NO. 50-272 UNIT NO. 1 LICENSEE EVENT REPORT 91-011-00 This Licensee Event Report is being submitted pursuant to the requirements of the Code of Federal Regulations 10CFR

50. 7 3 (a) ( 2) ( i) ( B)

• This report is required to be issued within thirty (30) days of event discovery.

Sincerely yours,

/A'.//0,1f?tw~

S. LaBruna General Manager -

Salem Operations MJP:pc Distribution 9104010366 910320 PDR ADOCK 05000272 S

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HllC Forlll 3M U.I. NUCLEAR llEOULATOllY COMMISllO.N 19..31 . ,_,,.ROVED .OMB NO. 3150-4104 EXPIRES: 1/311115 LICENSEE EVENT REPORT (LER)

FACILITY NAME C1l DOCKET NUMBER 121 *

• I PAGE 131 Sa1em Generating station -*unit 1 o 1s I o Io I o 12 I 71 2 1 loF o 13 TITLE 141 High Rad Area Found Unlocked/Unguarded Due To Personnel Error '

EVENT DATE 151 LER NUMBER 181 REPORT DATE 171 OTHER FACILITIES INVOLVED Ill FACILITY NAMES DOCKET NUMBERISI 01s1010101 I i THIS REPORT 11 IUBMITTED PURIUANT TO THE REQUIREMENn OF 10 CFR §: (Chock OM Of man of rh* fol/owfngl 1111 Ol'ERATIHO

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LICENSEE CONTACT FOR THIS LER 1121 ll0.73(1lf2llwllllfll .

ll0.731111211*1 NAME TELEPHONE NUMBER AREA CODE M. J. Pollack - LER Coordinator COMPLETE ONE LINE FOR E.l,CH COMPONENT FAILURE DESCRIBED IN THll REPORT 1131 .

MANUFAC- SYSTEM COMPONENT MANUFAC-CAUSE SYSTEM COMPONENT TURER

• TURER I I I I .I I I I I I I I I I I I I I I I I *1 I I I I I I IUPPLEMENTAL REl'ORT EXPECTED (141 MOlllTH DAY ~AR EXPECTED SUBMISSION n YES (If yn, comp/tr. E~PECTEO SUBMISSION DA TEI **r-xi NO DATE 1151

.I .I I On February 20, 19.91 at 1020 hours0.0118 days <br />0.283 hours <br />0.00169 weeks <br />3.8811e-4 months <br />, the RHE Room was discovered to be unlocked and unguarded by Radiation Protection Department supervision. The access door to this room was found closed. On February 19, 1991 *at 2300 hours0.0266 days <br />0.639 hours <br />0.0038 weeks <br />8.7515e-4 months <br />, .during ninth refueling outage activities, the Regenerative Heat Exchanger (RHE) Room High Radiation Area (HRA) key was obtained by a Radiation Protection technician to support work in the area. Work in the area was completed at 0200 hours0.00231 days <br />0.0556 hours <br />3.306878e-4 weeks <br />7.61e-5 months <br /> on February 20, 1991. The area has accessible (by climbing) radiation levels of up to 2.0 R/hr at 18 inches from the heat exchanger. The ground level area radiation levels are less than 1 R/hr. The* root cause of this event is personnel error. The Radiation Protection technician, who was supporting work in the RHB Room, did.

not ensure the door was locked after personnel vacated the area. The technician upon closing the door verified it latched closed but did not ensure it was locked (turned the knob). This event has been reviewed.by Radiation.Protection Department management. Corrective discipline was taken with the technician responsible for this event.

This event has been reviewed with applicable Radiation Protection Department personnel stressing the need for ensuring positive control of HRA's. Access logs and personnel dosimetry data were reviewed for the period between February 19, 1991 at 2300 hours0.0266 days <br />0.639 hours <br />0.0038 weeks <br />8.7515e-4 months <br /> to February 20, 1991 at 1200 hours0.0139 days <br />0.333 hours <br />0.00198 weeks <br />4.566e-4 months <br />. No inadvertent entry into the RHE room was apparently made. The RHE access door is now chain locked. The door locking mechanism will be replaced with a mechanism that requires key removal for the door to be locked.

HRC f<><ft!l :!.U

• Salem Generating Station

• LICENSEE EVENT REPORT (LER) TEXT CONTINUATION DOCKET NuMBER LER NUMBER

• PAGE Unit 1 . 5000272 91-011-00 2 of 3 PLANT AND SYSTEM IDENTIFICATION:

I Westinghouse - Pressurized Water Reactor Energy Industry Identification System (EIIS) codes are identified in

• the text as {Xxf IDENTIFICATION OF OCCURRENCE:

High Radiation Area found unlocked/unguarded due to personnel error

• Event Date: 2/20/91 Report Date: 3/20/91 This report. was initiated by Incident Report No'.91-122 *

. CONDITIONS PRIOR TO OCCURRENCE:

Mode 5 (Cold Shutdown) - gt h Refueling out.age DESCRIPTION OF OCCURRENCE:

. On February 19, 1991 at 2300 hours0.0266 days <br />0.639 hours <br />0.0038 weeks <br />8.7515e-4 months <br />, during .ninth* refueling* outage .

activities, the. Regenerative Heat Exchanger (RHE) Room High Radiation Area (BRA) key was obtained by a Radiation Protection technician to support inservice inspection work in the area. Work in the area was completed at 0200 hours0.00231 days <br />0.0556 hours <br />3.306878e-4 weeks <br />7.61e-5 months <br /> on February 20, 1991. This room is a High Radiation. Area. It has accessible (by climbing) radiation leve.ls of up to 2.0 R/hr at 18 inches from the heat exchanger. The ground level area.radiation levels are less than 1 R/hr.

On February 20, 1991 at 1020 hours0.0118 days <br />0.283 hours <br />0.00169 weeks <br />3.8811e-4 months <br />, the RHE Room was discovered to be unlocked and unguarded by Radiation Protection* Department supervision.* The access door to this room was found closed.*

Having an unlocked/unguarded HRA, where radiation levels of greater than 1.0 R/hr are accessible (by climbing), is contrary to the requirements of* Technical Specification 6.12 and Radiation Protection Procedure RP 203, "Radiation Protection Ke:f Control System".

APPARENT CAUSE OF OCCURRENCE:

The root cause of this.event is personnel error. The Radiation Protection technician, who was supporting the inservice inspection work in the RHE Room, did*not ensure the door was locked after personnel vacated the area (i.e., completion of work activities). The technician upon closing the door verified it latched closed but did not ensure it was locked (turned the knob).

The RHE Room access door is not necessarily self locking. If the key is turned in one direction it is self locking while the other direction produces the opposite result. Although this factor contributes to the cause of this event, technicians are trained to positively verify that BRA accesses are locked once all personnel have

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LICENSEE EVENT REPORT (LER) TEXT CONTINUATION Salem Generating Station -DOCKET NUMBER LER NUMBER PAGE Unit- 1 5000272 91-011-00 3 of 3 APPARENT CAUSE OF OCCURRENCE: (cont'd)

_vacated - the area. . Also, Radiation Protection pro*cedure RP-203, section 6.4,* requires the technician_to verify the door is locked and secure upon exit of the -BRA.

ANALYSIS OF OCCURRENCE:

Access to HRA's is controlled to prevent personnel from unknowingly entering areas where excessive radiation dose could be accumulated.-

The subject BRA contained radiation levels ranging up to 2.0 R/hr (at 18") in reasonably assessable areas.

Upon discovery, the RHE access door was locked as required. This occurrence involved no undue risk to the health and safety of the public. *However, because this occurrence involves a situation contrary to t_he requirements of the Technical Specifications,. this event is reportable in ~ccordance with the Code of Federal Regulations 10CFR 50. 73 (a) (2) (i). (B).

CORRECTIVE ACTION: .

This _event has been reviewed by Radiation Protection Department management. Corrective discipline was taken with the technician responsible for this event.

This event has been reviewed with applicable Radiation Protection*

Department personnel stressing the need for ensuring positive control of HRA's.

Access logs and personnel dosim~try data were reviewed fo~ the period between February 19, 1991 at 2300 hours0.0266 days <br />0.639 hours <br />0.0038 weeks <br />8.7515e-4 months <br /> to February 20, 1991 at 1200 hours0.0139 days <br />0.333 hours <br />0.00198 weeks <br />4.566e-4 months <br />. No inadvertent entry into the RHE room was apparently made.

The RHE access door is now chain locked. The door locking mechanism will be_replaced with a mechanism that requires the door_to be locked for-key removal.

A review of all other locked HRAs was conducted. No other access locking mechanisms were identified with similar concerns to the RHE

-Room door.

Past unlocked/unguarded BRA events, occurring within the last four years*, have been reviewed. These other events did not involve the RHE Room access door nor were their root causes similar to this event.

/Jffi/rtk/4'~,___--

General Manager -

Salem Operations MJP:pc SORC Mtg.91-032