ML20058H393

Insp Rept 50-374/93-34 on 931102-09.Violations Noted.Major Areas Inspected:Special Reactive Insp of Circumstances & Events Re Administrative Overexposure of Worker While Performing Post Maint Valve Testing in Pump Room on 931031

ML20058H393
Person / Time
Site:	LaSalle
Issue date:	12/06/1993
From:	Michael Kunowski, Louden P, Snell W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20058H372	List: ML20058H368 ML20058H381 ML20058H393
References
50-374-93-34, NUDOCS 9312130067
Download: ML20058H393 (6)

See also: IR 05000374/1993034

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U.S. NUCLEAR REGULATORY COMMISSION

REGION III

Report No. 50-374/93034(DRSS)

Docket No. 50-374

License No. NPF-18

Licensee: Commonwealth Edison Company

Post Office Box 767

Chicago, IL 60690

Facility Name:

LaSalle County Station, Unit 2

Inspection At:

LaSalle County Station, Marseilles, Illinois

Inspection Conducte :

November 2 throu

9, 1993

Inspectors:

A

/R

Patrick L. Louden

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Radiation Specialist

/Y

8. N h

(2/C/fJ

Michael A. Kunowski

Date

Senior Radiation Specialist

Approved By- M

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WiTliam Snell, Chief

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Radiological Programs Section 2

Inspection Summary

Inspection on November 2 throuah 9. 1993 (Report No. 50-374/93034(DRSS))

Areas Inspected:

Special reactive inspection of the circumstances and events

involving the administrative overexposure of a worker while performing post

maintenance valve testing in the Unit 2 reactor water cleanup hold pump room

on October 31, 1993.

Results:

Two violations of NRC requirements were identified. The first

violation involved inadequately placing the reactor water cleanup system out-

of-service (00S) which resulted in the "B"

filter 'demineralizer being

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backwashed while the system was drained, which caused a 90 rem /hr (0.9 Sv/hr)

hot spot in the area in which a worker was standing. 'The second violation was

associated with the inappropriate actions of the worker who, when hearing the

electronic dosimeter _he was wearing alarm, did not immediately leave the area

as directed by.the radiation work permit (RWP) under which he was working.

A

second example of a failure to follow RWP requirements was also identified, in

that, this same worker entered a contaminated area which contained

contamination levels greater than 50,000 dpm/100cm' (833.3 Bq/100cm') wearing

minimal protective clothing (PCs). The RWP did not allow for the wearing of

minimal PCs in contaminated areas greater than 50,000 dpm/100cm (833.3

9312130067 931206

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Bq/100cm') . This event is a continuing example of the licensee's failure to

recognize the potential for changing radiological conditions and the overall

stationwide lack of respect for the radiation hazards encountered in day-to-

day operations within the plant.

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DETAILS

1.

Persons Contacted

Licensee staff

• J. Arnould, Regulatory Assurance

• J. Atchley, Asst. Superintendent of Operations

• R. Bare, Senior Quality Controls Inspector

• J. Bell, Supervisor, Maintenance Support Staff

• M. Friedmann, Technical Lead Health Physicist

• S. Harmon, Supervisor, Training Department

• R. Haynes, Station Quality Verification

• K. Kociuba, Master Electrician, Electrica1' Maintenance

• J. Lockwood, Supervisor, Regulatory Assurance

• J. McIntyre, Superintendent, Station Quality Verification

• E. McVey, Regulatory Assurance

• L. Oshier, Health Physics Services Supervisor

• R. Ragan, Supervisor,-Systems Engineering

• J. Rodriguez, Senior Radiation Protection Technician

• M. Santic, Superintendent, Maintenance Department

• C. Sargent, Superintendent, Site Services

• J. Schmeltz, Superintendent, Operations

• J. Terrones, Station Quality Verification Inspector

Nuclear Reaulatory Commission

• H. Clayton, Chief, Reactor Projects Branch 1

• C. Pederson, Chief, Reactor Support Programs Branch

• D. Hills, Senior Resident Inspector

• C. Phillips, Resident Inspector

Illinois Deoartment of Nuclear Safety

• J. Roman, Resident Engineer

The inspector also interviewed other licensee personnel in various

departments in the course of the inspection.

• Indicates those present at the exit meeting on November 9, 1993.

2.

Administrative Overexoosure Event of October 31. 1993

On October 31,- 1993, during the evening shift,.two operators (0pl, Op2)

were given their shift duties to perforg post maintenance. valve testing

on several valves associated with the ' Unit 2 Reactor Water Cleanup.

(RWCU) system. They reported to the radiation protection (RP) desk

where survey maps were reviewed with the radiation protection technician

(RPT) at the desk and high radiation area keys were provided for access

to rooms on three elevations of the Unit 2 reactor building. The

operators performed their inspections on the-761' and 807' elevations

and noted alleaking valve which would have to be repaired prior to their

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continuation of work on the 807' and other elevations.

Sometime during

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this part of the shift they where assigned by control room personnel to

backwash the "B" RWCU filter demineralizer.

During the initial phases

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of the backwash, Op1 entered the hold pump room to verify the proper

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cycling of the F0010B valve which actuates during the early stages of

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the backwash process (the F0010B valve is located in the same general

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area where Op2 later entered the room and received the higher dose).

Op1 exited the room and went back to the RWCU control panel to finish

the backwash with Op2.

Following the completion of the backwash, Op2

entered the hold pump room to verify proper cycling of the F0032B valve

(an air operated ball valve). Op1 began the valve cycling via the RWCU

control panel. Op2 heard the solenoid actuate on the valve.

He also

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noticed a whining noise which at the time he attributed to air movement

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associated with the opening of the valve. After the valve had cycled

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open (approximately 30 seconds), Op2 noticed that the whining noise was

continuing and he noticed that the noise was his electronic dosimeter

al arming. Op2 pulled the dosimeter'from his pocket and.saw a reading of

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220 mrem (2.2 mSv) and increasing (while standing in the same area). He

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left the area immediately after seeing the high reading on the'

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dosimeter.

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Op2 reported to RP with his electronic dosimeter in alarm.

The alarm

was indicating both high dose rate and accumulated dose. The RP shift

foreman cleared the dosimeter and dispatched a RPT to the room to

determine the cause of the alarm. Subsequent surveys revealed a 90

rem /hr (0.9 Sv/hr) hot spot in a pipe which was about head-high in the

area where Op2 was standing. The pipe exhibited dose rates from 50 to

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90 rem /hr (0.5 to 0.9 Sv/hr) throughout the length of pipe surveyed.

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Following this event, the RP department examined the historical data

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recorded by the two operators' dosimeters. Op1's dosimeter indicated

the highest dose field encountered to be 140 mrem /hr (1.4 mSv). Op2's

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dosimeter showed the highest dose field encountered to be 5 rem /hr (0.05

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Sv/hr).

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J_nspection Findinos

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The inspectors reviewed the event through interviews with cognizant

individuals involved and observed the RP department's followup time

motion study to ascertain the actual whole body dose received by the

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worker.

Based on reviews of followup radiation surveys, the worker.

sheuld have encountered a dose rate field which would have caused his

dosimeter to alarm well before he arrived at the location of the valve

in which he was to inspect.

Interviews with the worker indicated that

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he could not recall hearing the dosimeter alarming.

The dosimeter was

tested and re-calibrated after the incident and was found to be in' good

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working order.

The inspectors attended the time motion study performed by the RP

department to ascertain the actual whole body dose rate fields the

individual encountered and to determine the actual whole body dose

received. The worker was wearing his dosimeter in his right chest

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pocket. The highest dose rate field registered on the dosimeter was 5

rem /hr (0.05 Sv/hr). Adjusting for the height of the worker and his-

relative position tc the 90 rem /hr (0.9 Sv/hr) source, it was determined

that the worker's head was in a 18 rem /hr (0.18 Sv/hr) dose rate area.

The time-motion studies indicated that the worker's head was in this 18

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rem /hr (0.18 Sv/hr) dose rate field for approximately 2 minutes. The

corrected exposure values based on the time / motion study compared well

with the accumulated dose recorded on the electronic dosimeter for the

dose rate fields the dosimeter was actually within.

Based on the

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adjusted exposure values the worker's corrected exposure for the entry

was recorded as 655 mrem (6.55 mSv), and 699 mrem (6.99 mSv) total

external exposure for the day.

This total was well above the daily

administrative exposure limit of 100 mrem (1 mSv) but under the

regulatory limit of 1,250 mrem / quarter (12.5 mSv/ quarter). The

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inspectors verified that the worker had a current NRC Form 4 on file

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which would have allowed the individual to receive a quarterly

regulatory dose of 3000 mrem (30 mSv) for the quarter. Adding the

adjusted exposure for this event to the worker's previously recorded

quarterly dose gave the individual a quarterly total of 887 mrem (8.8

mSv) for the current quarter.

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Based on further review of the event the inspectors noted the following

contributors /causes to the event:

The RWCU system was not appropriately placed 00S.

When the

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system was placed 00S on or about October 1, 1993, the 00S

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package stated to verify that the system had been shutdown

according to RWCU procedures.

LOP-RT-12, step F.5, states

that all filter demineralizer trains are to be backwashed

prior to removing the entire system from service.

This

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failure to perform the backwash prior to the shutdown of the

system as required was a contributing root cause of the

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creation of the hot spot.

This failure to follow a

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procedure described in Regulatory Guide 1.33, as referenced

in Technical Specification 6.2. A is a violation of the RWCU

system shutdown procedure LOP-RT-12, step F.5. (Violation

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50-374\\93034-01)

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Based on followup surveys, Op2's electronic dosimeter should

have alarmed from a high dose rate several feet before he

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reached the area of the F0032B valve.

The worker should

have responded to the alarming dosimeter by immediately

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leaving the area when hearing the alarm as directed in the

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RWP under which he was working.

(Violation 50-374\\93034-

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02a)

During the investigation following the event, the worker

displayed an attitude of "getting the job done" rather than

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to heed dosimeter alarms.

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The worker was also not appropriately dressed in protective

clothing (PCs) for the entry into the contaminated area

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which contained contamination-levels greater than 50,000

dpm/100cm (833.3 Bq/100cm'). The RWP did not allow the

wearing of minimal PCs for areas with such contamination

levels. (Violation 50-374\\93034-02b)

The backwash procedures did not include any type of

notification to RP to perform followup surveys to ensure

radiological conditions had not changed. However, past

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experience with the system in normal configuration,

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indicated no radiological problems associated with the

backwash.

Two violations of NRC requirements were identified. One weakness with

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respect to identifying the potential for radiological conditions was

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identified.

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Exit Meetina

The scope and findings of the inspection were discussed with licensee

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representatives (Section 1) at the conclusion of the inspection on

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November 9, 1993.

Licensee representatives did not identify any

documents or processes reviewed during the inspection as proprietary.

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Specific items discussed at the meeting were as follows.

The two apparent violations of concern which occurred during the

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event,

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NRC management's concerns with the attitude of radiation workers

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and particularly station management to respect the radiological

hazards encountered in the plant.

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A discussion to the effect that this event would be reviewed for

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the substantial potential for an overexposure.

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