ML20207S632

Reactive Safety Insp Rept 50-333/87-07 on 870218-20. Violations Noted:Failure to Control Dry Tube Cutting Activities in Reactor Refueling Pool.Worker Received Exposure of Approx 29.6 Rems to Right Hand

ML20207S632
Person / Time
Site:	FitzPatrick
Issue date:	03/09/1987
From:	Lequia D, Shanbaky M NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:
Shared Package
ML20207S620	List: ML20207S619 ML20207S632
References
50-333-87-07, 50-333-87-7, NUDOCS 8703200114
Download: ML20207S632 (12)

See also: IR 05000333/1987007

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U.S. NUCLEAR REGULATORY COMMISSION

REGION I

Report No. 87-07

Docket No. 50-333

License No. DPR-59

Priority

Category

C

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Licensee: Power Authority of the State of New York

P. O. Box 41

Lycoming, New York 13093

Facility Name: James A. FitzPatrick

Inspection At: Scriba, New York

Inspection Conducted:

February 18-20, 1987

Inspectors

4%E

J-9-87

. P. LeQuiafJadia)/lo~n Specialist

date

Approved by:

MV/,

mIM/

3[9 /f 7

M. Shanbaky,~ thief, Facilitjes Radiation

d'ats

Protection Section

Inspection Summary:

Insoection Report No. 50-333/87-07

Areas Inspected: A reactive inspection to examine the events which lead to an

extremity exposure for one worker in excess of NRC limits. The worker received

a near instantaneous exposure of approximately 29.6 rems to the right hand.

NRC regulations limit extremity exposure to 18.75 rems / quarter.

Results: Within the scope of this inspection, five (5) apparent violations

were identified relative to failure to adequately control dry tube cutting

activities in the reactor refueling pool.

(see Section 3.0 for a description

of the event and Section 6.0 for NRC findings). These multiple failures to

control the work activity lead to an extremity exposure in excess of federal

regulatory limits.

8703200114 870311

PDR

ADOCK 05000333

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DETAILS

1.0 Personnel Contacted

1.1 Licensee Personnel

During the course of this inspection .the following personnel were

contacted or interviewed:

• R. Beedle, Vice President, Nuclear Support - NYPA, WP0

• R. Converse, Resident Manager, FitzPatrick Station

• W. Fernandez, Superintendent cf Power

• E.' Mulcahey, Radiological and Environmental

Services Superintendent

• B. Baker, Maintenance Superintendent

• H..Keith, Instrument and Controls Superintendent

• D. Lindsey, Operations Superintendent

• R. Liseno, Planning Superintendent

• D. Patch, Quality A:surance Superintendent

• A. McKeen, Assistant to Radiological and Environmental

Services Superintendent

"G. Vargo, Radiological Engineer

B. Sarkissian, Refueling Floor Supervisor

J. McCarty, Radiological and Environmental Services Supervisor

F. Petschauer, Radiological Engineer, WPO, (acting Assistant

Radiological and Environmental Services Supervisor)

N. Morris, Senior Health Physic Technician

K. Smith, Radiological and Environmental Services Technician

J. Lennier, Nuclear Services Technician

Other licensee or contractor personnel were also contacted.

1.2 NRC Personnel

• M. Shanbaky, Chief, Facilities Radiation Protection Section

• A. Luptak, Senior Resident Inspector

• Denotes attendance at the Exit Meeting held on February 20, 1987.

2.0 Purpose

The purpose of this special inspection was to examine the events which

lead to an extremity exposure of one worker in excess of NRC limits and to

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-assess licensee control over radiological work activities relative to this

overexposure. During this incident, a worker received an exposure of

approximately 29.6 rems to his right hand.

The exposure was instantaneous

in nature and occurred as a result of a worker grasping a highly radio-

-active piece of material for one to two seconds. NRC regulations limit

extremity exposures to 18.75 rems / quarter.

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3.0 Description of Events

On February 13, 1987, at 0648, Special Radiation Work Permit (RWP) number

87-2099-S was initiated to continue Intermediate Range Monitor (IRM)/

Source Range Monitor (SRM) instrument dry tube cutting and removal from

the reactor vessel. These dry tubes, located inside the reactor vessel,

are highly radioactive and require underwater cutting with a special tool.

Dry tube cutting operations had been ongoing for several days.

The two (2) Radiation Protection (RP) technicians designated to provide

radiological control for the cutting activity, entered the work area at

approximately 0730: ahead of the work crew to set up the area. Upon

arriving on the refueling floor work area the technicians noted that an

extendable probe high range survey meter, that had been available their

previous shift, was missing. Not wanting to quit working at this point,

they continued to set up the work area. The RP technicians were not

given a pre-job briefing by the RP Supervisor, or by the Refueling Floor

Supervisor.

At approximately 0800, the Refueling Floor Supervisor, and four (4) con-

tractor personnel involved in the dry tube cutting operations, entered

the work area. They proceeded to set up their equipment. One of the RP

technicians, seeing that work was about to begin, left the refueling floor

in search of an extendable probe survey instrument. The other RP techni-

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cian stayed in the area to provide radiological controls for what he

thought would be moving of blade guides and bottom plugs to support the

dry tube cutting operation.

Contractor employees (at approximately 0855), under the direction of the

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Refueling Floor Supervisor (a licensed Senior Reactor Operator), proceeded

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to cut the top off of dry tube SRM "D" at location 20-17. The cutter tool

was then transported underwater to the spent fuel pool where a catch pan

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was located to receive the cut tube segments. Once over the pan the tool

was opened and a segment (approximately 18" long) was observed to fall

from the cutter into the pan. The tool was then visually inspected under-

water and believed to be empty. The tool was then raised toward the

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surface in preparation to remove it from the water to inspect the cutter

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blade and make any necessary repairs. This is standard operating proce-

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dure since the cutter blade must be checked after each cut.

The RP tech-

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nician, thinking that no dry tubes had been cut and that the tool was

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being removed to check it out prior to any cutting operations, allowed

the work to progress. The RP technician then started an air sampler and

proceeded to become actively involved in the work by washing down the cable

and cutter tool.

(This work is normally done by contractor personnel who

were present at the work site.) The RP technician did not perform a radio-

logical survey of the tool as it approached and broke the water surface.

(The extendable probe instrument still wasn't available.) Furthermore, he

was too busy with the air sample and water washdown to use his hand held

ion chamber instrument.

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As the cutting tool was removed from the water, a local radiation monitor,

installed about eight (8) feet away on the refueling bridge, alarmed (set-

point 100 mR/hr).

Upon hearing the alarm, personnel immediately lowered

the tool back into the water and attempted additional flushing of the tool.

Simultaneously, unbeknown to refueling floor personnel, the New Fuel Vault

area radiation monitor (ARM-14), located about forty-three (43) feet away,

had.also alarmed in the control room.

Control room persunnel silenced the

alarm, but did not take any action to evacuate the area or direct addi-

tional radiation surveys of the area.

In addition, the Auxiliary New Fuel

Vault monitor (JB-ARM-7), located on the refueling floor, failed to alarm.

Subsequent investigation by the licensee determined that the audible alarm

function had been by passed by removing an " electrical jumper".

Examina-

tion of this auxiliary monitor by the inspector also found that the visual

meter indication was obscured due to material stacked in front of it.

Direct communication between the Refueling Floor Supervisor and the

control room, previously required by Procedure RAP 7.1.23 " Removal and

Installation of IRM/SRM Instrument Dry Tubes", had been cancelled by a

temporary procedure change on February 12, 1987. (This temporary change

has since been cancelled as part of the corrective actions).

About one (1) minute later, at approximately 0901, the RP technician, who

stated he had not heard the alarm, nor being informed of the alarm by the

Refueling Floor Supervisor, allowed the tool to be lifted out of the water

again. . At this point, again unknown to refuel floor personnel, the New

Fuel Vault monitor (ARM-14) and the Spent Fuel Pool radiation monitor

(ARM-12; set point 25 mR/hr; and located over fifty (50) feet away)

alarmed in the control room. The local monitor again alarmed on the

refueling bridge and was oscillating between 300-400 mR/hr. However,

personnel on the refueling bridge did not believe the instrument indi-

cation, attributing the alarm to instrument failure. The RP technician

was not made aware of these alarms.

The tool continued to be raised up and over the refueling pool railing.

The RP technician stopped rinsing the tool and reached for his handheld

survey meter (R0-5). As the tool was moving rapidly towards the floor he

performed a cursory survey of the cutting tool, obtaining a dose rate

indication of 2.'1 R/hr.

(Instrument response timo takes 5-7 seconds to

reach 90% of full scale). Unaware of instrument response times and think-

ing this dose rate was normal, since previous " empty" surveys on the tool

had ranged from approximately 500 to 2500 mR/hr, the technician allowed

work to continue.

Upon placing the tool on the floor, a 4-5" long piece of dry tube was

jarred from the tool.

The contractor worker, seeing the piece of tube,

reacted instantly, grasped the tube in his right hand and threw it back

into the water. Subsequent processing of the worker's finger ring TLD

revealed an exposure of approximately 29.6 rems to the right hand of the

worker.

Later, underwater surveys on the segment of dry tube, performed

by licensee, indicated 13,000 R/hr. The licensee determined that this is

equivalent to approximately 16,300 R/hr in air.

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The contract worker then began to remove the cutter blade and hydraulic

cylinder from the tool for inspection. However, a survey of the cutter

tool was not performed after the piece of tube fell out and prior to the

worker beginning to remove the cutter blade and mechanism. Shortly there-

after, the RP technician performed a survey of the tool and found it tc be

reading 568 mR/hr.

By approximately 0904, the control room had cleared the ARM alarms and had

received a call from the Refueling Floor Supervisor (RFS) telling them

about the incident.

Based on the information provided by the RFS, control

room personnel thought everything was under control and took no further

action, since the radioactive piece of dry tube was back in the water.

Meanwhile, on the refueling floor, work continued as normal.

At approximately 0930, the RP techniciaa covering the work exited the

work area to process an air sample. When he checked his direct reading

dosimeter (DRD), he found both the low range (0-200 mrem) and high range

(0-500 mrem) DRDs off-scale. He immediately notified the other workers

on the refuel floor and instructed them to read their DRDs. The contract

worker, who had handled the dry tube, was only wearing a 0-200 mrem DRD,

which was also off-scale. The remaining workers each received exposures

of less than 100 mrem for the event. Processing of the wholo body TLD

badges for the RP technician and contract worker indicated they each had

received exposures of approximately 450 mrem. (The licensee is currently

calculating upper arm exposures and evaluating beta contribution for the

extremity exposure of the worker).

The contract worker and the RP technician left the refuel floor and went

to dosimetry to turn in their monitoring badges.

Personnel on the refuel

floor continued working, with a different RP technician providing coverage.

Work progressed until about 1030 when Radiological and Environment Services

(RES) Supervision (a synonym for Radiation Protection Supervisor) talked

to the RP technicians involved in the incident. At that point RES Manage-

ment finally became aware that a potentially significant unplanned exposure

had occurred. At this time, tube cutting work was suspended pending

investigation of the incident by the licensee.

4.0 Scope of NRC Review

NRC review and evaluation of the events causing and contributing to the

extremity overexposure included the following:

interviews with involved personnel;

discussions with cognizant RP supervisory and technical personnel;

direct inspection of the refueling floor work area;

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review of RWP 87-2099-S and associated ALARA review 87-013;

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review of NRC Form 4 for the contract worker and RP technician

personnel involved;

review of refueling floor RP logbooks;

review of survey records associated with dry tube cutting and;

review of applicable station procedures and Technical Specifications.

5.0 NRC Findings

A.

Limiting Exposur_e: 10 CFR 20.101(a), in part, limits the extremity

exposure of an individual in a restricted area to 18.75 rems per

calendar quarter.

Inspector review of dosimetry records for the contract worker who

handled the dry tube segment indicated that the worker received a

near instantaneous exposure of approximately 29.6 rem to the right

hand.

Failure by the licensee to control worker extremity exposure

to less than 18.75 rem for the first calendar quarter of 1987 con-

stitutes an apparent violation of 10 CFR 20.101(a) (50-333/87-07-01).

B.

Training:

10 CFR 19.12 " Instructions to Workers" requires, in part,

that occupational radiation workers be instructed in, amongst other

things,-the health protection problems associated with exposure to

such radioactive materials or radiation, (and) in precautions or

procedures to minimize exposure.

The inspector interviewed the contract worker, the two RP technicians

covering the work, and the RP Supervisors involved with the activity.

These interviews were conducted to determine the experience levels of

the personnel and to evaluate their understanding of the workscope

and associated radiological and procedural controls for dry tube

cutting.

It was determined from these interviews that both the RP Supervisor

and RP technicians had limited experience with dry tube cutting. The

technicians had only been partially involved with tFe cutting of one

tube previously. The technicians further indicated that they were

unaware of the content and radiological precaution * associated with

procedure RAP 7.1.23 " Removal and Installation of IRM/SRM Instrument

Dry Tubes," Rev. 1.

Compounding this lack of job knowledge, neither

the RP Supervisor nor the Refueling Floor Supervisor briefed or

instructed the technicians on the health physics problems associated

with dry tube cutting (RWP 87-2099-S specifically required a pre plan

meeting to be conducted).

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Interviews with the contract worker found him to nave significant

tube cutting experience. However, during the interview he stated

that he had not received any instruction on the radiological protec-

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tion problems associated with dry tube cutting, or of his required

actions to minimize exposure if a chip or piece of dry tube was found

in/out of the cutting tool.

Failure to adequately instruct and brief RP technicians on the content

and radiological precautions contained in procedures associated with

the work they are covering; and failure to brief the contract worker

in the radiological protection problems associated with dry tube

cutting, as well'as his actions and responsibilities if a highly

radioactive piece of material was located, constitutes an apparent

violation of 10 CFR 19.12 (50-333/87-07-02).

C.

Surveys:

10 CFR 20.201(a) defines " survey" as an evaluation of the

radiation hazards incident to the production, use, release, disposal

or presence of radioactive materials.

10 CFR 20.201(b) requires

licensees to make such surveys as necessary to comply with the reg-

ulations and are reasonable to evaluate the extent of radiation

hazards that may be present.

Licensee personnel had routinely performed radiological measurements

of the cutting tool when it was pulled from the water. However, when

the extendable probe high range survey instrument was missing, a

suitable replacement was not obtained in a timely manner.

Subsequently,

the cutting tool was moved towards the surface of the water and finally

out of the water without taking the necessary measurements to evaluate

the radiological hazards. However, upon receiving a local radiation

monitor alarm, the cutting tool was placed back into the refueling

pool.

After flushing, the cutting tool was again lifted out of the water

and moved towards the work area. A radiation measurement was con-

ducted at this time, and erroneously indicated 2.1 R/hr.

This survey

was inadequate, since it failed to detect a piece of dry tube with an

exposure rate of approximately 16,300 R/hr lodged in the tool. The

RP technician received 2.4 rems to his hand while performing this

survey.

After the segment of dry tube fell from the cutter, the contract

worker then began inspection of the cutter blades and mechanism.

However, the RP technician had not surveyed the tool after the dry

tube segment fell out and prior to the worker handling the tool.

This presented a hazard since the previous shift had found a 415 mR/hr

" chip" in the tool.

Shortly after repair work commenced on the tool,

a radiation measurement was conducted and indicated 568 mR/hr.

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These three examples of failure to survey constitutes an apparent

violation of 10 CFR 20.201(b) (50-333/87-07-03).

D.1 Procedures: Technical Specification.6.11 requires in part that pro-

cedures be developed and followed to implement the requirements of 10 CFR 20.

1.

Station procedure RPOP-4 " Radiation Work Permit" in part

requires that personnel comply with all dosimetry equipment

required by the RWP.

2.

Station Procedure RPOP-7 " Radiological Incident Investigations"

in part requires that work be stopped following an incident and

that RES Supervision be notified.

When the RP technician directed the contract worker to read his DRD,

it was discovered that the worker only had a low range DRD. RWP

(87-2099-S) specifically required a high range (0-500 mrem) DRD be

worn.

Further licensee investigation of the event determined that

two additional personnel were not equipped with high range DRDs as

required.

Furthermore, while the radiological incident occurred at approxi-

mately 0900, personnel continued to work until about 103u. Work

continued even after two personnel were found to have DRDs with

off-scale readings.

Failure to: 1) wear required dosimetry devices, and 2) stop the

associated work and notify RES Supervision as required constitutes

two examples of apparent Technical Specification 6.11 violations

(50-333/87-07-04).

In addition, inspector review of the procedures to control the work

activity, specifically:

RPOP-1, " Refueling Floor Shutdown Surveys", Rev.1; and

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RAP 7.1.23 " Removal and Installation of IRM/SRM Instrument Dry

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Tubes", Revision 1;

found the procedures to be significantly weak in the delineation of

authority and responsibility. Additional weaknesses included very

few radiological precautions to ensure the safe conduct of the work

activity. The licensee has since recognized these weaknesses, and

has taken action to upgrade both procedures.

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D.2 Procedures

1.

Technical Specification 6.8 " Procedures" requires in part that

written procedures and administrative policies shall be estab-

lished, implemented and maintained that meet or exceed the

requirements and recommendations of... Appendix A of Regulatory

Guide 1.33, November 1972.

Appendix A of Regulatory Guide 1.33 states, in part, that

procedures for " Bypass of Safety Functions and Jumper Control"

should be established.

During interviews with personnel, the inspector determined that

the Auxiliary New Fuel Vault monitor (JB-ARM-7), located on the

refueling floor, had not alarmed to warn workers of change in

radiological conditions. Through further discussions with these

personnel, it was determined that the audible alarm function had

been circumvented by removing an electrical lead from the control

box to the alarm horn. The disabling of the audible alarm was

subsequently confirmed by the Radiation Protection Manager.

Station procedure WACP 10.1.3 " Jumper Control", in part, defines

the removal of an electrical wire from a circuit as a jumper.

Licensee personnel were unable to determine how long this jumper

had been removed.

Inspector

examination of the auxiliary

monitor further revealed that the visual meter indication had

been obscured by stacking equipment in front of the monitor.

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Failure to implement the " Jumper Controls" of procedure WACP

10.1.3 constitutes an apparent violation of Technical Specifi-

cation 6.8 (50-333/87-07-05).

6.0 Contributing Factor

NRC investigation of the event also identified another problem with

radiological controls the'. potentially affected dry tube cutting

acti vi t f e's . Although this problem did not appear to be directly related

to the overexposure, it may be a contributing factor and is deserving of

note and specific attention by the licensee.

Inspector evaluation of the "ALARA Review" (87-013) for dry tube replace-

ment found it to be weak.

Specifically, licensee personnel did not

recognize the potential radiological hazards associated with tube cutting,

and, therefore, did not include precautions on the ALARA review for this

work.

Instead, the ALARA review concerned only the under reactor vessel

portion of the work.

Furthermore, Step 5.3.1, of REP-1 "ALARA Review",

in part, requires that "should unanticipated radiological conditions be

encountered, the ALARA review should be revised...."

However, the ALARA

review was not revised even though unanticipated radiological conditions

had been encountered on the shift previous to the overexposure. On that

shift, a 415 R/hr " chip" was found in the cutting tool.

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7.0 Licensee Corrective Actions

At approximately 1030, on February 13, 1987, the licensee secured work on

dry tube cutting, and commenced investigation into the incident.

The

licensee interviewed the individuals involved in the extremity overexposure

incident, including: Radiation Protection, supervisory and worker personnel.

From these interviews, they concluded that failures to comply with company

procedures and policies did exist in relationship to the extremity over-

exposure for one of the workers.

In addition, the licensee conducted two

sessions of a Plant Operations Review Committee (PORC) to evaluate the

event and develop corrective actions.

Based on their findings, the licensee

allowed work to recommence on February 15, 1987, with the following addi-

tional controls implemented to prevent recurrence:

1.

Required a pre-job briefing prior to each significant job evolution;

2.

Revised RAP 7.1.23 " Removal and Installation of IRM/SRM Instrument

Dry Tubes" and RPOP-1 " Refueling Floor Radiation Protection

Coverage" to:

require RP " approval / coverage" prior to bringing tools and

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equipment out of the water;

delineate the responsibilities of the Refuel Floor Supervisor, ~

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Control Room Operator, RES Supervision and Radiation Protection

Technician (s);

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warn personnel of the high' spec 1_fic ' activity.cf the a:ompone.nts -

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in the reactor vessel and actions they are to take if-

irradiated parts or particles get on the floor;

require the use of an extendable probe survey instrument for

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pool work;

require two (2) RP technicians to survey the dry tube cutter

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when it is removed from the pool;

3.

Will include the incident in GET training for the next two outages to

strengthen awareness.

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Conducted a detailed training session (pre-job type) with all

involved personnel prior to restart of work following the incident.

During this training, the event was fully related and the revised

procedures were discussed with all involved personnel.

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Reminded RP technicians about survey instrument response times.

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The licensee indicated that a long-term corrective action would be

the development of a check-off sheet to assist with pre-job planning

and documentation,

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The inspector reviewed licensee corrective actions anc noted tnat

they appeared to be extensive. However, dry tube cutting activities

were complete, and, therefore could not be evaluated in practice.

The inspector discussed the corrective actions with the licensee,

stating that several of the corrective actions (i.e. pre-job planning,

upgraded supervisory responsibilities, and procedure improvements)

were nearly identical to corrective actions for a previous, similar

event which occurred during the last refueling (see Section 8.0).

However, the licensee had not adequately implemented these corrective

actions.

Since previous corrective actions had not been adequately implemented,

the inspector asked the licensee how they would ensure that the current

corrective actions were properly implemented.

The licensee indicated

that they would have to evaluate appropriate methods to address this

concern.

8.0 Historical Review

During the previous refueling outage, in April 1985, the licensee

experienced similar problems relative to surveying the dry tube cutting

tool when removing it from the refueling pool.

Specifically:

Inspection Report 85-12, Appendix A, Notice of Violation A.3, stated in

part"...that personnel pulled the [ cutting] tool out of the reactor

cavity and were permitted to handle the tool prior to radiation surveys

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being made of_ the tool. . A radiation protection technician with a survey

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meter was about 15 feet away~ when the tool was~ removed, handled, and

bagged by two workers."

Partial correction actions for the above violation included the following:

1.

Once each normal work shift an RES Supervisor will observe the more

radiologically sensitive jobs while in progress for the purpose of

verifying that procedures are being followed.

These observations

will be reported to the RESS, who will then brief the Superintendent

of Power.

2.

There will be pre-job planning of the more sensitive jobs conducted

by an RES Supervisor with the (RP) technician assigned coverage.

Additional long-term corrective action was to include the development

of work practice guides, which would address removal of equipment

from the refueling and spent fuel pools.

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NRC review of these corrective actions had found them to be adequate

at the time of the inspection (Inspection Report 85-30). However,

over time their corrective actions were not followed. When the

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inspector discussed this situation with licensee management, they

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indicated that some of the corrective actions had been documented on

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a memo (JSOP-85-037), then filed and overlooked.

The licensee is

continuing their investigation as to what happened .to the work

practice guides.

9.0 Exit Meeting

The' inspectormetwithlicenseemanagementdenotedinSection5.0on

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February 20, 1987, at the conclusion of the inspection. The scope and

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findings of the inspection were discussed at that tinie. At no time was

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written material provided to the licensee.

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