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 NRC/IE
To:
References
IN-86-044, NUDOCS 8606040010
Download: ML031250056 (5)

LIS ORIGINAL SSINS No.: 6835 IN 86-44 UNITED STATES NUCLEAR REGULATORY

COMMISSION

OFFICE OF INSPECTION

AND ENFORCEMENT

WASHINGTON, D.C. 20555 June 10, 1986 IE INFORMATION

NOTICE NO. 86-44: FAILURE TO FOLLOW PROCEDURES

WHEN WORKING IN HIGH RADIATION

AREAS

Addressees

All nuclear power reactor facilities

holding an operating

license (OL) or a construction

permit (CP) and research and test reactors.

Purpose

This information

notice is provided to alert licensees

of the problem of recurring, unauthorized

entries by maintenance

workers into high radiation areas. A recent event is discussed

below, and a related event is summarized

in Attachment

1. Since the workers ignored and bypassed maintenance

procedures

that include radiological

controls established

to limit exposures

in high radiation

areas, it is fortuitous

that during these entries no personnel exposure limits were exceeded.It is expected that recipients

will review this notice for applicability

to their 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 requirements

and, therefore, no specific action or written response is required.Past Related Correspondence:

INPO Significant

Event Report (SER) 50-85, "Uncontrolled

Personnel

Radiation Exposure," November 4, 1985 (discusses

two events).INPO Significant

Operating

Experience

Report (SOER) 85-3, "Excessive

Personnel Radiation

Exposures," April 30, 1985 (discusses

seven events).IE Information

Notice No. 84-19, "Two Events Involving

Unauthorized

Entries Into PWR Reactor Cavities," March 21, 1984.IE Information

Notice No. 84-59, "Deliberate

Circumventing

of Station Health Physics Procedures," August 6, 1984 (discusses

six events).8606040010

IN 86-44 June 10, 1986 Description

of Circumstances:

On January 8, 1986, at Turkey Point, an instrument

and controls (IC) technician

made 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 health physics (HP) technician

providing

job coverage, the IC technician

had made adjustments

to the TIP drive unit (dose rates only 5 to 25 mR/hr), which later enabled the technician

to successfully

withdraw the TIP into the accessible

TIP drive work area.During the unauthorized

entry, the IC technician

received 500 millirem whole body exposure during an approximately

5-minute stay time in a work area, which was later calculated

to be 6 R/hr in the general area. The radiation

level 1 foot 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 survey instrument (scale of 0-1 R/hr) used by the IC technician

upon entering the high radiation

area initially

moved up the scale to 800 mR/hr and then reportedly

went rapidly down the scale to zero, when moved closer the the radiation source. The IC technician

failed to recognize

the malfunctioning

survey instrument

and stayed in the area to complete his maintenance

task. At these dose rates, it was fortuitous

that the technician

did not remain in the TIP area for any longer period.Subsequent

licensee and NRC regional review of the event revealed several key factors that contributed

to the incident.1. Failure To Follow Procedures

Numerous procedural

violations

occurred before and during the unauthorized

entry. These violations

included failure to notify HP personnel

before operating

the TIP, performing

craft work outside the scope of the author-ized plant work order (PWO), and making entry and working alone on the TIP system.2. Personnel

Shortcomings

The IC technician's

foreman failed to clearly define the TIP system problem and provide adequate instructions

on the PWO. The IC technician

failed to obey the local radiological

area warning, a posting that read "high radiation

area -keep out." Inadequate

training caused the IC technician

to fail to recognize

a malfunctioning

survey instrument (downscale

reading caused by GM detector tube continuous

discharge

response to intense radiation

levels), which he was using to help control his exposure.The NRC noted subsequent

to the event that, although not contributory

to this incident, governing

maintenance

procedures

for the TIP system did not require tagging out of other operable TIPs (to prevent inadvertent

withdrawal

into an occupied work area) with work in progress on a malfunctioning

TIP unit. For future TIP work, the licensee agreed to control movement of the irradiated

TIPs with equipment

tag out controls.

IN 86-44 June 10, 1986 Discussion:

The NRC continues

to note repeated occurrences

of unauthorized

entries into high 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 radiation work permits (RWP), or both, is a central cause of the exposure incidents.

Adherence

to work/surveillance

procedures

forms a basic framework

for providing effective, consistent

radiological

controls for work in high radiation

areas.Short of providing

direct, continuous

health physics coverage for each and every task, these procedures

serve as the formal mechanism

for initiating

necessary

communications

between various plant worker crafts groups and the health physics support group. This communication

results in appropriate

radiological

support (e.g., RWP issuance)

for the maintenance/surveillance

activities.

Bypassing

these procedures

and thus failing to comply with the radiological

precautions

in them seriously

weakens the health physics control program 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

in high radiation

areas, appropriate

enforcement

action has been proposed for the Turkey 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 Regional Administrator

of the appropriate

regional office or this office.dwari o Jor , D irector Division of Emergency

Preparedness

and Engineering

Response Office of Inspection

and Enforcement

Technical

Contacts:

James E. Wigginton, IE (301) 492-4967 Roger L. Pedersen, IE (301) 492-9425 Attachments:

1. Related Exposure Event 2. List of Recently Issued IE Information

Notices

Attachment

1 IN 86-44 June 10, 1986 RELATED EVENT SUMMARY At the Cooper Nuclear Station on August 28, 1985, two IC technicians

performed maintenance (TIP alignment)

as required by a craft work procedure.

Contrary to the work procedure's

radiological-cautions

warnings, these workers failed to obtain a special RWP and entered the TIP drive enclosure

housing, ignoring the access posting, "Notify Health Physics Prior to Opening." The TIP maintenance

procedure

further warned that the drive unit's Gleason reel is spring loaded and the incore detector could be withdrawn

by the spring tension. It further warned that the withdrawn

incore detector probe could be highly radioactive.

Upon opening the unsurveyed

enclosure, they found the TIP had withdrawn

into the enclosure

and the detector had broken off. The technicians

immediately

exited the high radiation

and high airborne radioactivity

area. The indivi-duals each received approximately

200 mrem whole body exposure and airborne intakes of 44 and 90 MPC-hrs.As corrective

actions, the licensee (1) stressed to all station personnel

the importance

of properly following

radiological

controls and (2) revised the governing

maintenance

procedure

to require written documentation (signoff)notifying

HP before working on the TIP system.

Attachment

2 IN 86-44 June 10, 1986 LIST OF RECENTLY ISSUED IE INFORMATION

NOTICES Information

Date of Notice No. Subject Issue Issued to 86-43 Problems Sampling iodine With Silver Zeolite Of Airborne Radio-86-42 Improper Maintenance

Radiation

Monitoring

Of Systems 86-41 86-32 Sup. 1 86-40 86-39 86-38 Evaluation

Of Questionable

Exposure Readings Of Licensee Personnel

Dosimeters

Request For Collection

Of Licensee Radioactivity

Measurements

Attributed

to The Chernobyl

Nuclear Plant Accident Degraded Ability To Isolate The Reactor Coolant System From Low-Pressure

Coolant Systems in BWRS Failures Of RHR Pump Motors And Pump Internals Deficient

Operator Actions Following

Dual Function Valve Failures Degradation

Of Station Batteries Change In NRC Practice Regarding

Issuance Of Confirming

Letters To Principal

Contractors

6/10/86 6/9/86 6/9/86 6/6/86 6/5/86 5/20/86 5/20/86 5/16/86 5/16/86-All power reactor facilities

holding an OL or CP All power rector facilities

holding an OL or CP All byproduct material licensees All power reactor facilities

holding an OL or CP All power reactor facilities

holding an OL or CP All power reactor facilities

holding an OL or CP All power reactor facilities

holding an OL or CP All power reactor facilities

holding an OL or CP All power reactor facilities

holding an OL or CP 86-37 86-36 OL = Operating

License CP = Construction

Permit