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{{Adams
#REDIRECT [[IR 05000440/1989016]]
| number = ML20244C235
| issue date = 06/05/1989
| title = Insp Rept 50-440/89-16 on 890502-0602.Violations Noted Re Inadequate Surveys & Failure to Use Dosimetry in High Radiation Area.Major Areas Inspected:Allegations of Possible Overexposure.Overexposure Probably Did Not Occur
| author name = Greger L, Kunowski M, Schumacher M
| author affiliation = NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
| addressee name =
| addressee affiliation =
| docket = 05000440
| license number =
| contact person =
| document report number = 50-440-89-16, NUDOCS 8906140171
| package number = ML20244C228
| document type = INSPECTION REPORT, NRC-GENERATED, INSPECTION REPORT, UTILITY, TEXT-INSPECTION & AUDIT & I&E CIRCULARS
| page count = 11
}}
See also: [[see also::IR 05000440/1989016]]
 
=Text=
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L
                                                                                U. S. NUCLEAR REGULATORY COMMISSION
l
                                                                                                        REGION III
  ..
l                                    Report No. 50-440/89016(DRSS)
.
'
                                    Docket No. 50-440                                                                                                              License No. NPF-58
                                    Licensee: Cleveland Electric Illuminating Company
                                                Post Office Box 5000
l-                                              Cleveland, OH 44101
l                                    Facility Name: Perry Nuclear Power Plant, Unit 1
                                    Inspection At: Perry Site, Perry, Ohio
                                    Inspection Conducted: Hay 2 through June 2, 1989
                                    Inspectors:            M. A. Kunowski M . M. k                                                                                                    8~
                                                                                                                                                                                        /
                                                                                                                                                                                          ///f
                                                                                                                                                                  LYdte
                                                            R. J. Caniano                            $pY                                                                      b [//@
                                    Reviewed By:
                                                            '- 7 27 M A
                                                            M. Schumacher, Chief                                                                    #***/h[.                          /
                                                            Radiological Controls                                                                                    Date
                                                              and Che stry Section
                                                              N                                                                                                                Gff'f6
                                    Approved By:          L. Ro/bertGreger,Chif
                                                            Reactor Programs 9 ranch                                                                                Date
                                    Inspection Summary
                                    Inspection on May 2 through June 2, 1989 (Report No. 50-440/89016(DRSS))
                                    Areas Inspected: Special, announced inspection to review allegations of
                                    a possible overexposure.
                                    Results: The inspectors' review of this event indicated that an overexposure
                                    probably did not occur; however: a potential for one appears to have existed.
                                    The radiation field intensity was not known at the time of entry. Also,
                                    the worker exited the area without completing his work assignment because he
                                    noted an unexpected SRD reading. The inspectors identified several radiological
                                    control weaknesses attendant to the event, including inadequate surveys in
                                    support of an RWP and a lack of aggressiveness and curiosity by the radiation
                                    protection technicians covering the drywell during the incident. Four
                                    allegations related to the incident were unsubstantiated; two allegations
                                    were substantiated (Sections 2 and 3). Four apparent violations of regulatory
                                    requirements were identified, including (1) inadequate surveys, (2) failure to
                                    document a survey, (3) failure to follow radiological control procedures for
                                    installation of shielding and for initiating a radiological occurrence report,
                                    and (4) failure to use appropriate dosimetry in a high radiation area.
                                    (Sections 2 and 3).
                                            Rf$bCsb
                                                                          '
                                                                                                  sf
                                            *
                                                                                                                            -  - - - -                                          -----                        -J
 
                                                                                                          _
        -
  .
-    *
    ,
          ..
                                                                                                            )
                                                                                                            i
                                                DETAILS
                                                                                                            1
          1.  Persons Contacted                                                                            1
              *R. R. Bowers, Corporate Health Physicist
              *W.  E. Coleman, Manager, Operations Quality Section
              +G.  R. Dunn, Lead Engineer, Licensing and Compliance Section, Perry
                  Plant Technical Department (PPTD)                                                        1
              *M. W. Gmyrek, Manager, Perry Plant Operations Department                                    j
            +*H. L. Hegrat, Operations Engineer, Licensing and Compliance Section
                J. V. Ivery, Superintendent, R. J. Frazier
              *S. F. Kensicki, Director, PPTD
              *R. A. Newkirk, Manager, Licensing and Compliance Section                                    i
                R. W. Parsons, Superintendent, R. J. Frazier                                                1
                C. Reiter, Health Physics Supervisor, PPTD                                                  {
                T. E. Shega, System Engineer, PPTD
              *L. L. VanDerHorst, Plant Health Physicist, PPTD
            +*F. C. Whittaker, Lead Health Physics Supervisor, PPTD
              *S. J. Wojton, Manager, Radiation Protection Section, PPTD
              The inspectors also contacted other licensee employees, including
              technicians, workmen, and supervisors.
              *G. F. O'Dwyer, NRC Resident Inspector
              * Denotes those present at the exit meeting on May 10, 1989.
              + Denotes those present at the exit telephone meeting on June 5, 1989.
          2.  Allegation Followup
              (Closed) Allegation (AMS No. RIII-89-A-0054)                                                  l
                                                                                                            l
              a.    Allegation Concern No. 1: A worker may have been overexposed during
                    a job.
                    An allegation concerning a possible overexposure was received
                    in the Region III office on April 10, 1989; subsequent telephone
                    conversations with the alleger were held on April 27. May 11, and
                    May 31, 1989. The alleger stated that on March 24, 1989, a worker
                    may have been overexposed when he was allowed to work in an unexpectedly
                    high radiation field near a hotspot that was later determined to be
                    12 R/hr on contact. Several concerns were expressed by the alleger,
                    namely, that the worker was blamed for the exposure, that the RPM
                    may have been covering up the exposure, that the Radiation Work
                    Permit (RWP) for the job was not properly written, that the hotspot
                    in the pipe should have been shielded, and that the worker had not
                    been issued proper dosimetry for the job.
                    These allegations were reviewed by Region III inspectors during a
                    special onsite inspection on May 2-3, and May 8-10, 1989 and in
                    subsequent telephone discussions with licensee representatives                        1
                                                    2                                                      i
                                                                                  - _ _ _ _ _ _ _ _ -__-
 
                                                      -_ -          _  _
                                                                            - _ _ _ - - -
li.^    -
l '.) -  ,
1
            through June 2, 1989. The inspection consisted of record and
            procedure review, job site observations, and interviews of workers
            .and licensee technical _and management personnel.
            Discussion: On March 24,1989, at 6:45 p.m. , the worker, who is a
            pipefitter, and his foreman entered the drywell on RWP 890335 to
            provide support for inservice inspection (ISI) work. Attached
            to the RWP.were several survey maps for various-locations in the
            drywell, including the general areas in which the men had to go.
'
            The men stated they notified the radiation protection technicians
            (RPTs) at-the drywell access control desk before entry, as required
            by.the RWP, and were told of the radiological conditions in the
            areas in which they had to work, as shown on the survey maps.
            The individuals then entered the drywell and first went to the
            reactor water cleanup (RWCU) system on the 583' elevation. After
            approximately 30 minutes, the men left this area and went to the
            630' elevation to scope another job, removal of pipe supports
            (snubbers and pipe clamps) on the low pressure coolant injection
            (LPCI) line. The supports are located about 2' upstream of a LPCI
            line check valve in an approximately 3.5' x 5' x 6' pit, adjacent
            to, but below, the 630' elevation walkway. This pit is normally
            not accessible from the walkway, being enclosed by jet shielding;
            however, some of the jet shielding had been removed on March 22,
            1989, allowing access to it.
            Within the pit, the foreman recorded some preliminary data and
            explained to the worker what had to be done for the job. The men
            left the area after approximately 15 minutes (at about 8:00 p.m.)
            and returned to the drywell exit.    As they left the drywell, they
            told the RPTs that they had received approximately 30 mrem, an
            unexpected amount, on their SRDs during their short time at the LPCI
            job site.    The RPTs attributed this exposure to the time the workers
            spent at the RWCU job, where the general area dose rates ranged from
            100-150 mrem / hour, and not the LPCI job,'where general area dose
            rates supposedly ranged from 5-18 mrem / hour, according to the posted
            survey, dated May 16, 1989, taken before the jet shielding was removed.
            No records were found which showed that a survey of the pit area was
            conducted after removal of the jet shielding on March 22 and the
              initial pit entry by the workers on March 24.
            The RPT who was named in the allegation stated that after the men
              left he surveyed the pit and identified a 2.5 R/ hour (contact)
            hotspot on the LPCI pipe about 3' downstream of the snubbers, and
            also measured general area dose rates of 80-100 mR/ hour. These
            general area levels were about a factor of ten higher than those
            measured during the survey of March 16, 1989, which was being used
              to allow entry under the RWP. However, the March 16, 1989, survey
            was done with the jet shielding in place and, therefore, did not
              properly characterize the radiological conditions in the pit. The
              licensee's use of an inappropriate survey to govern RWP entry is an
              apparent violation of 10 CFR 20.201(b), which requires the licensee
                                            3
                                                                                        - - _ _ _ _ _ _ _ _ _ -
 
      --      .
            -
    .
  *
        .'    -
                  .to make surveys that are necessary and reasonable to evaluate the
                  extent of radiation hazards that may be present
                  (No. 440/89016-01a).
                  In addition, the inspectors determined that the survey identifying
                  the 2.5 R/ hour hotspot was not documented, an apparent violation of
                  the 10 CFR 20.401(b), which requires the licensee to maintain records
                  of surveys required by 10 CFR 20.201(b) (No. 440/89016-02).
                  At 11:45 p.m., the foreman and the worker returned to the drywell,
                  with a second worker.  The RPT stated he informed them of the survey
                  results including the hotspot. (However, the worker and the foreman
                  stated to the inspectors that they were not informed of any hotspot.
                  The foreman stated that he and the RPT went to the work area, where
                  the RPT explained that he had surveyed the area earlier in the day
                  and that dose rates along the bottom of the pipe were 80 mR/ hour
                  and indicated that general area dose rates were lower. The worker
                  stated that the survey results that were relayed to him were general
                  area dose rates were 30-40 mR/ hour.)
                  The worker stated he began the job, assisted by the second worker,
                  who did not enter the pit, but stayed on the 630' walkway to get
                  tools as needed. Meanwhile, the foreman, with the agreernent of
                  the RPT, obtained lead shielding and gave it to the workers, who
                  " hung" it on the pipe near the snubbers. However, it appears that
,
                  the lead shielding was not placed around the pipe elbow, the spot
                  identified by the RPT as the hot spot,-but on a horizontal section
                  of the pipe near the snubbers.
                  They continued working until the first worker read his low-range
                  SRD, and observed what he thought was movement of the SR0 hairline.
                  (Both workers stated to the inspectors that the worker read the SRD
l
                  because of.his apprehension about the radiation hazards in the area
I
                  and not because of such instructions by the RPT.) The workers
                  immediately left the area and went to the drywell exit where they
                  informed the named RPT of the behavior of the SRD.                          The worker
                  estimated that he had been in the pit for 35 to 40 minutes before he
                  left.
                  The RWP record shows 210 mR total dose based on the worker's
                    low range SRD; the RPT stated that the worker's high-range SRD
                    read 50 mR. The RPT also stated that he told the worker that the
                  discrepancy may be due to a faulty low-range SRD. (It was later
                    ascribed by health physics management to differences in location                              ,'
                    of the two dosimeters with respect to the hotspot.)
                  The RPT stated that sometime later he resurveyed the pit with a
                    different meter and found that the intensity of the hotspot had
                    increased to 3.5 R/ hour and the general area dose rates had
                    increased to 300-400 mR/ hour. The technician then returned to the
                    drywell exit and informed the workers of the survey results. (The                            !
                    workers claim that when the technician returned, he apologized to
                                                  4
                                                            -        . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - - _ _ - _
 
          _ ._ _    _- _      _ _ .
        .
    .
'
  .  .
                ,
f                    them saying, in effect, that the meter he used for the previous
                      survey must have been defective, and that there was a hotspot in the
                      elbow of the pipe and general area dose rates were 300-400 mR/ hour.
                    The workers then left the drywell, at about 12:30 a.m. , on March 25,
                      1989.
                    Another foreman (the general foreman) stated to the inspectors
                      that after hearing of the hotspot, he borrowed a Bicron Model
                    Tech 50 G-M survey meter from the RPTs at the drywell control
                      desk and surveyed the elbow.    He stated that he measured 5 R/ hour
                      on contact with the elbow (5 R/ hour is the highest value obtainable
                  -with this model survey meter.)
                    According to the technician, after he informed the workers of the
                      survey results he informed his supervisor of the apparent change
                      in the radiological conditions in the pit. Subsequently, no further
                    entries were allowed, pending an ALARA review. The RPT documented
                      his survey approximately 30 minutes later, at 1:00 a.m.              There
                      is no record of the survey by the general foreman.
                      During his next shift (on Saturday night, March 25th), the RPT-
                      stated that he again surveyed the work area in the pit and determined
                      that the hotspot was now reading 12 R/ hour and the general area dose
                      rate was 1 R/ hour. For this survey, the RPT climbed down into the
                    pit, whereas, for the two previous surveys, he-did not enter the pit,
                    but just reached in with his meter from the walkway. An inspection
                      of the work area by an NRC inspector indicated that because of the
                      narrow, partially obstructed opening to the area, and the position
                      of the 12" LPCI pipe in the pit, an adequate survey of the work area
                      could not have been made from the walkway with the type of survey
                    meter uscd by the technician. Performing the two surveys of the
                    pit frow the walkway is another instance of an apparent violation
                      of 10 CFR 20.201(b), which requires the licensee to make surveys
                      that are reasonable to evaluate the extent of radiation hazards
                      that may be present (No. 440/89016-01b).
                      On his next shift, (Saturday-Sunday, March 25-26), the worker
                      discussed the incident with an HP supervisor who took the worker's
                    TLD for processing, and began an investigation to determine if an
                      overexposure had occurred. Later, the worker discussed the incident
                    with the HP supervisor responsible for external dosimetry on
                      nightshift. This supervisor apparently tried to allay some of the
                      worker's concerns, and provided, at the worker's request, a
                      preliminary dose estimate that ranged from 210 mrem to 7000 mrem.
                      The 210 mrem value was the worker's recorded dose for the job
                      according to the low-range SRD and the 7000 mrem value was a
                      worst-case estimate assuming the worker was in contact with a
                      3.5 R/ hour hotspot for the entire 2 hours he spent in the drywell.
                      The supervisor then refined the estimate by assuming 20% of the time
                      was spent in transit to and from the work area, and explained to
                      the worker that even this simple assumption would change the upper
                      estimate from 7 rem to 4.76 rem. (The supervisor stated in a memo
                                                    5
                                                                          - - - _ _ _ - _ _ _ _ - _ _ -
 
        .
  v      .
  -    "
            .
    .,
f
                dated March 26, 1989, that he later realized that he miscalculated
                the value, noting that 80% of 7 rem is 5.6 rem, not 4.76 rem.) After
                discussing this estimate and general information on the effects of
                radiation, the supervisor and the worker then discussed other
                details of the job.
                During the remainder of the week, the plant HP staff.made a more
                formal evaluation of the potential doses to the worker and the
                foreman. The evaluation used personal dosimetry results, a detailed
              . survey of the work area, and times and distances obtained from a
                reenactment of the job in the dose reconstruction. The reenactment
                was performed in the pit using an HP supervisor of similar height
                as a surrogate for the worker. The reconstruction for the worker
                assumed:
                (1) The head 12 inches from the hotspot for 26.5 minutes in a field
                      of 500 mR/hr;
                (2) The head 9 inches from the hotspot for 26.5 minutes in a field
                      of 1000 mR/hr; and
                (3) The head 3 inches from the hotspot for two minutes in a field
                                              ~
                      of 3500 mR/hr.
                (According to licensee representatives, distances referenced for the
                dose rates were measured from the pipe to the center of the detector
                which is located approximately 1 1/2 inches from the base of the
                survey meter.)
                The resulting dose estimate to the head of the worker was 780 mrem
                for his two entries into the pit.    A similar but more detailed
                scenario was used to estimate 346 millirems for the foreman's
                entries (17 minutes) into the pit. The corporate health physicist
                made. independent dose estimates based on the worker's dosimeter
                readings and allowing for attenuation through the body but using the
                same dose rate-time scenario.    He obtained 750 and 860 mrem for the
                worker's high and low range dosimeters, respectively, which are not
                significantly different from the 780 mrem estimated by the station
                staff.
                The reconstruction was necessitated by the absence of dosimetry on
                the portion of the total body (the head or top of the back) nearest
                the hotspot.  The reconstruction for the foreman appears better
                because it was based on his detailed written description of his
                actions and assumes a short period in contact with the pipe. The
L
                reconstruction for the worker assumed no contact time despite the
                worker's assertion that he leaned against the pipe (although not
                necessarily the hot spot). An NRC inspector who entered the pit
,
                noted that it was neither difficult nor awkward to place his head
l                on the LPCI pipe. The worker told NRC representatives that he was
j                not sure of time or positions with reference to the hotspot.
                                                6
 
        _ _ _ _ _ _ _ _ - _ _ _ _ -_            _.  _
{w                                .
-                            *
                                      .
                    .
                                          While the licensee's dose estimate of 780 mrem for the worker may
                                          be a reasonably good estimate of his actual dose, there is an
                                          uncertainty associated with this estimate due to the worker's stated
                                          lack of specific recollection of his body movements in the pit.
                                          However, because the worker did not recall having his head in
                                          contact with the pipe for a significant length of time, it does not
                                          appear that even under conservatively assumed conditions, he could
                                          have received a dose in excess of regulatory limits.
                                          Finding: This allegation could not be substantiated. It appears,
                                          based on the results of this inspection, that no overexposure
                                          occurred although the worker's dose may have been underestimated
                                          by assuming that no time was spent in direct contact with the
                                          hotspot. However, a potential for an overexposure did exist and
                                          an overexposure may have occurred if the worker had not left the
                                          work area when he did and/or if the hotspot radiation levels had
                                          been higher.    Two apparent violations of NRC requirements were
                                          identified.
                                        b. Allegation Concern No. 2: The RPM told the worker that the exposure
                                          was the worker's fault.
                                          Discussion: The RPM denied making a statement of this nature to the
                                          worker.  The RPM stated to the inspectors that while discussing the
                                          incident with the worker and hearing comments from the worker
                                          concerning how many times he questioned the RPTs about the dose
                                          rates in the area that he (the RPM) did tell the worker that if he
                                          was not satisfied with the answers he was getting from the techs
                                          that he should have pursued the matter at a higher level, as allowed
                                          and encouraged by station policy.
                                          Findings: The RPM made a statement that could be interpreted as
                                          ascribing fault to the worker; however, the RPM denied that was the
                                          intention.    The allegation was not substantiated. No violations of
                                          NRC requirements were identified.
                                        c. Allegation Concern No. 3: The alleger stated that he was concerned
                                          that the RPM may be covering up the alleged overexposure because the
                                          RPM would not allow the worker to see or copy any of the records
                                          pertaining to the incident, and because of the RPM's statement that
                                          he (the RPM) "never had anyone burned out at Perry" and that he
                                          would evaluate the dose and "it will probably be under 1000 mR."
                                          This concern was reinforced by the fact that another HP supervisor
                                          had earlier given him an exposure estimate of 4.78 rem (The
                                          licensee's memo of March 26, 1989 refers to this estimate as
                                          4.76 rem. See Allegation Ccncern No. 1.)
                                          Discussion: The RPM stated to the inspectors that the worker
                                          requested to review or receive copies of some records but that
                                            he declined because the evaluation was not yet complete. The RPM
                                            stated that the worker was told that copies could be requested after
                                          completion of the evaluation. On May 2, 1989, the RPM told the
                                                                          7
  _ _ - _ _ _ _ - _
 
      _ - _ _ _ - .
[  .                  r-
$. -              ,.
                      4
                          ,
                                inspectors that the evaluation had been completed but no request
                                from the worker had been received. He further stated that he had
                                no reason:to deny the worker's request and, in fact, had responded
l
                                to a similar request from the foreman for his records. He added
l                              that such detailed records are not normally given to workers.
,-
                                The RPM told the inspectors that he did not remember making the
                              ' statement that he "never had anyone burned out at Perry," but stated
                              -that he did tell the worker that it was not Perry's policy to " burn
                                out" workers; but rather it was Perry's policy to minimize dose to
                                the individual and to groups of workers, and to equally distribute
                                dose as much as possible. He also stated that his forecast of under
                                1000 mR was based on his knowledge of the tentative results of the
                                evaluation then in progress, which was much more plausible than the
                                crude.4.76 rem estimate made before detailed measurements were taken
                                in the pit.
                                Findings: The inspectors could not substantiate the allegation
                                that the RPM was concealing information from the worker regarding
                                the worker's exposure. The RPM acknowledged that records of the
                                incomplete evaluation were not given to the worker but stated that
                                the worker was told he could request a copy of the evaluation when
                                completed. No violations of NRC requirements were identified.
                            d.  Allegation Concern No. 4: The Radiation Work Permit (RWP) for the
                                job on which the alleged overexposure occurred was not properly
                                written.
                                Discussion: TheallegerstatedthathewastoldbytheALARA
                                Coordinator (name unknown) that the HP department ' screwed up the
                                                                                                                  '
                                RWP." The inspectors interviewed the members of the ALARA staff,
                                including the dayshift and nightshift ALARA Coordinators, and
                                several ALARA Specialists. The nightshift ALARA Coordinator
                                remembered being questioned by an individual unknown to him about
                                the incident but stated that he did not remember making such a
                                statement about the RWP to the individual, and probably would not
                                have made such a statement. RWP No. 890335, written March 1, 1989,
                                covered in-service inspection and support work which included snubber
                                removal in the pit. The RWP covered such work, throughout the
                                drywell. It specified that HP be notified before the start of work
                                so that area conditions may be established and also required either
                                HP coverage or a dose rate meter to enter a high radiation area
                                (HRA). The entire drywell was posted as an HRA with control over
                                entry exercised at the HP desk at its entrance where the RWP sign-in
                                sheets are kept. In this case, area conditions were established not
                                from a survey at the time of entry on March 24, but from the record
                                of.a survey made on March 16, as noted in the discussion under
                                Allegation Concern No. 1, this survey was inadequate because it did
                                not accurately depict conditions in the pit at the time of entry.
                                  Finding:  The RWP, although very generally written, was adequate to
                                prevent this occurrence had it been followed; therefore the
                                                                8
                                                                                      __ - -_-_____________ _ _ -
 
  _
        -_-      _ _ _ _
              *
      .
    ,-      ,
l              ,
:
l
                          allegation was unsubstantiated. However, overall radiological
                          control was vitiated due to inadequate surveys to establish
                          radiological conditions, as described under Allegation Concern
                          No. 1.
                  e.      Allegation Concern No. 5: A pipe with a hotspot should have been
                          shielded during the work in the area.
                          Discuss.ig : _ Station practice is to shield or flush hotspots before
                          allowing work to proceed and if not practical, then to use other
                          means to limit worker exposure such as restricting staytime or using
                          alarming dosimeters. The opportunity to use such controls before
                          work in the pit began on March 24 was missed due to the inadequate
                          survey previously discussed. Also, the controls were not imposed
                          before worker reentry following discovery of the 2.5 R/hr hotspot.
                          Shielding was hung by the workers after reentry, at about 11:45 p.m.
i                        However, it was not hung in accordance with Perry Administrative
                          Procedure PAP-0122, " Selection and Use of Temporary Shielding,"
                          which requires completion of a request form PPNP No. 6623 and
                          an estimate by the ALARA Coordinator of the person-rem that would
                          be incurred if the shielding were not installed. Failure to
                          follow this procedure is an apparent violction of Technical
                          Specification 6.11.1 which requires adherence to procedures for
                          personnel radiation protection (Violation 440/89016-3a).
                          Finding: This allegation is substantiated.    Although licensee
                          procedures were vague on this point, good ALARA practice would have
                          dictated shielding the hotspot before work began in the pit; that
                          it was not hung then is an apparent result of the inadequate survey.
                          When it was hung, it was done so improperly. _0ne apparent violation
                          was identified.
                  f.      Allegation Concern No. 6: Dosimetry should have been placed on the
                          worker's head while working near the hotspot.
                          Discussion:    Based on discussions with the worker and the foreman, a
                          reenactment of the job, and survey information, it is apparent that
                          a steep dose gradient existed in the work area, and that the highest
                          dose during the job would have been to the head and upper back,
                          not the chest where the dosimetry was placed. The dosimeters
                          near the chest would have been subject to shielding from the worker's
                          body, whereas a dosimeter on the head or upper back would not.
                          Therefore, the dose recorded by the dosimeter near or on the chest
                          would be inaccurate. So too would the dose determined by
                          back-calculation from the dosimeter because of uncertainties in
                          position of the chest with respect to the source and because of
                          the varying shielding effect as the worker moved around in the
                          work area. 10 CFR 20.202(a)(3) requires each licensee to supply
                          appropriate personnel monitoring equipment to each individual
                          who enters a high radiation area. In apparent violation of this
                          requirement, the licensee did not supply appropriate personnel
                                                        9
                                                                                          __-_ _ -
 
                -_ _ _ _
    ,                                .
                                        .
  -
                          .
l
l
l
l                                                monitoring equipment to the two workers who entered the pit, a high
                                                radiation area, in that dosimetry was not placed on the part of
'
                                                the whole body subject to the highest dose (No. 440/89016-04).
                                                Findings: The allegation was substantiated.    One apparent violation
                                                of NRC requirements was identified.
                                        3. Licensee Performance
                                          This event revealed weaknesses in the licensee's radiological controls;
                                          most notable was the failure to adequately survey to determine
                                          radiological conditions attendant upon entry to the work area. This was
                                          significant because the controlling RWP was generally written, leaving
                                          radiological details to be determined by site-specific surveys. An
                                          adequate survey taken at entry should have resulted in identification of
                                          elevated radiation levels, an ALARA review, better worker instructions,
                                          and issuance of proper dosimetry such that the incident would have been
                                          avoided.  An inadequate survey tends to undermine the RWP system of
                                          controls.
                                          A related and perhaps more fundamental weakness was the apparent lack of
                                          curiosity by the radiation protection group covering the drywell work on
                                          March 24-25, 1989, when the exiting workers first expressed concern about
                                          their SRD readings and again after the 2.5 R/ hour hotspot was identified.
                                          Opportunities to avoid an incident were again lost due to lack of
                                          aggressive response by the radiation protection group.
                                          Lack of aggressiveness also appeared to be a weakness in the licensee's
                                          followup investigation of the event.    Problems identified by the
                                          inspectors included the following.
                                          *    The licensee did not begin an investigation of this event until
                                                the worker sought out an HP supervisor on the worker's next shift
                                                (Saturday-Sunday, March 25-26) with complaints concerning the
                                                event.  The foreman was not interviewed until two days after the
                                                incident (on Monday, March 27,1989), when he alto sought out an
                                                HP supervisor.
                                          *    The licensee's investigation was too narrowly focused and did not
                                                include other relevant documents such as the work order covering
                                                the worker and his foreman and the HP drywell logbook until their
                                                relevance was pointed out by the inspectors. Both of these records
                                                indicated that other workers involved in snubber related work had
                                                entered the same general area; however, subsequent licensee review
                                                of these entries indicated they were not in close proximity to the
                                                hotspot.
                                          *    The licensee had in place two procedures for conducting and
                                                documenting a thorough review which had not been invoked at the
                                                time of the inspection. Perry Administrative Procedure, PAP-0124,
                                                " Radiological Occurrence Reporting," should have been implemented
                                                by initiation of a Radiological Occurrence Report (ROR) shortly
                                                                              10
      _ _ _ _ _ _ _ - _ _ _ _ _ _ _ _
 
      -      _                                                                                    ._
    .
t        .
  .
          ,
                    after the event. This procedure (Section 5.1) defines a
                    radiological occurrence as "an event which results in or could
                    result in a violation of the intent of Perry radiological
                    procedures, practices, or policies; or personnel radiation exposures                i
                      in excess of administrative guides and 10 CFR 20 limits," The                      I
                    procedure also states (Section 3.4) " Individuals are responsible
                    for reporting radiological occurrences in a timely manner." Contrary
                      to this requirement, and thus in apparent violation of Technical
                      Specification 6.11.1, no ROR was initiated for this incident
                    although it violated the intent of Perry radiological procedures,
                      practices, and policies on ALARA and external exposure control
                      (No.440/89016-03b).
                An example of an apparent violation of NRC requirements was identified.
          4.  Exit Interview
                An exit interview was conducted with licensee representatives (Section 1)
                on May 10, 1989, to discuss the tentative findings and possible
                enforcement options. The inspector stated that although the event may
                not have resulted in an overexposure, a significant potential did exist
                for one. The inspector also identified several apparent violations
                including inadequate evaluation, failure to document a survey,
                unauthorized shielding placement, and failure to initiate an ROR. The
                licensee stated that a condition report (which has a higher threshold than
                an ROR) was being initiated. The licensee did not identify any material
                reviewed by the inspectors as proprietary.
                A telephone conversation was held with the licensee representatives
                (denoted in Section 1) on June 5. 1989, to discuss the inspection
                findings including apparent violations. The following matters were
                specifically addressed:
                a.    NRC determination that an overexposure apparently did not occur,
                      but that there may have been a substantial potential for one,
                b.    Other specific allegation findings.
                c.    Apparent violations for inadequate surveys (Section 2.a), for failure
                      to document a survey (Section 2.a), for installation of temporary
                      shielding and for failure to initiate a radiological occurrence
      .
                      report  both contrary
                      to use appropriate    to procedure
                                            dosimetry        (Sections
                                                      in a high        2.e
                                                                radiation  and 3)(, and failureSection 2
                                                                          area
                d.    Weaknesses in radiological controls related to the incident and in
                      the licensee's followup.
                e.    Confirmed the receipt of the list of topics to be specifically
                      addressed at the Enforcement Conference, and the time, dtte, and
                      location of the Enforcement Conference.
                                                    11
                                                            _.      _      - _ _ _ _ _ _ _ _ _ _-    -
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