ML102150404

Applicant-Northard Exhibit 17-Part 1 of 3 RCE Report 01157726 Rev. 2 Radioactive Material Shipment Exceeded DOT Limits

ML102150404
Person / Time
Site:	Prairie Island
Issue date:	10/30/2008
From:	Xcel Energy
To:	Atomic Safety and Licensing Board Panel
SECY RAS
Shared Package
ML102150401	List: ML102150402 ML102150403 ML102150404 ML102150405 ML102150406
References
50-282-LR, 50-306-LR, ASLBP 08-871-01-LR-BD01, CAP AR 01157726, RAS 18333 RCE 01157726
Download: ML102150404 (30)

Text

QF-0433. Rev 2. (FG-PA-RCE-OI) RCE Report Template Page I of 81 RCEREPORT Prairie Island Nuclear Generating Plant (l Xcel Energy-

[Radioactive Material Shipment Exceeded DOT Limits]

Event Date: October 30,2008 RCE 01157726 Rev. 2 CAP AR 01157726 RCE (Team) members:

Root Cause lnvestigator: Peter Wildenborg RCE ~eam Leader ~ / J ~ V;/ Date Bob Hlte Management Sponsor

!Std£..?LLJP't:, Date Form retained in accordance with record retention schedule identified in FP-G-RM-O I.

QF-0433, Rev 2, (FG-PA-RCE-O I) RCB Report Template Page 2 of 81 RCEREPORT Prairie Island Nuclear Generating Plant

'(l Xcel Energy-

[Radioactive Material Shipment Exceeded DOT Limits]

Event Date: October 30,2008 RCE 01157726 Rev. 1 CAP AR 01157726 RCE (Team) members:

Root Cause Investi gators: Christopher Lethgo, Kelly Vincent Approvals:

RCE Team Leader Date Management Sponsor Date Form retained in accordance with record retention schedule identified in FP-G-RM-O I.

QF-0433, Rev 2, (FG-PA-RCE-O I ) RCE Report Template Page 3 of 8 I RCEREPORT Prairie Island Nuclear Generating Plant fl Xcel Energy*

[Radioactive Material Shipment Exceeded DOT Limits]

Event Date: October 30, 2008 RCE 01157726 CAP AR 01157726 RCE (Team) members:

Root Cause Investigators: Jeff Kivi (I), Lori Engesser (3), Ben Homer (3), Gene Woodhouse (3)

Team Members: Paul Vitalis (I) (Monticello), Myke Mazzitello (I)

Team Leader: Jeff leClair (all)

Team Sponsor: Bob Hite (all)

Field Team Members: Clay Sweet (1), Scott Nelson (I)

Contract Assistance: Cliff Young, WMG (2)

Contract Ass istance: Kay W. Gallogly, The 42 Group, LLC (2)

Contract Assistance: Rob Fisher, Fisher Improvement Technologies (3)

Technical As istance: Mike Lantz (3)

Approvals:

Jeff leClair 03/0312009 RCE Team Leader Date Bob Hite 03/03/2009 Management Sponsor Date Form retained in accordance with record retention schedule identified in FP-G-RM-Ol.

QF-0433, Rev 2, (FG-PA-RCE-OI) RCE Report Template Page 4 of 8 1 Table of Contents Page #

I. Executi ve Summary ..................................................................... .. ............ ................. 5

n. Event Narrative ... ...................................... ... ....... .... ......... .... ........... ............................ 9 ill. Extent of Condition Assessment. .............................................................................. II IV . Previous Sirrtilar Events: ...................................................................... ..................... 19 V. Operating Experience: .......................................................................... ....... ............. 2 1 Vl. Radiological Safety Significance ..... ....... ... .................. ....... .. ........... ..... .................... 26 VIl Reports to External Agencies & the NSPM Sites .... .... ........ .. .......... ............... .. .. ...... 30 Vrn .Data Analysis ............................................................................................................ 3 1 A. Information & Fact Sources .................................... .............. .. .............................. 31 B. Evaluation Methodology & Analysis Techniques ... ......... .................. .................. 32 C. Data Analysis Summary ........ ............. .... ................. .......... .................. .. ............... 32 D. Failure Mode Summary ........................................................................................ 33 DC Root Cause and Contributing Causes ........ .. ............................................................. 36 X. Correcti ve Actions .................................................................................................... 38 Xl. References .. ............. ............ ..... ..................... ........... .......... ........... ............................ 46 XIl. Attachments ...... ....... ................ ... ............ ........... ......... ......... ....... ...... ...... ......... ......... 51 NOTE: When the term "discrete particle" is used in this RCE to refer to the radioactive particle that was present on the equipment shipped to Westinghouse or similar particle that could potentiaJly challenge shipping Iirrtits for allowable radiation levels. the term is defined as follows:

discrete particle - any radioactive particle with a I foot dose rate in excess of 10 mrem per hour with an RO-2, (windOW closed), or equivalent and can be tracked through a significant gradient (factor of 10) to the discrete radioacti ve particle.

Form retained in accordance with record retention schedule identified in FP-G-RM-Ol.

QF-0433, Rev 2, (FG-PA-RCE-OI) RCE RepOlt Template PageS or81 I. Executive Summary Problem Statement (As taken from the Charter):

On Thursday, 10/30/2008, a shipping container was received by the Waltz Mill site that exceeded 10CFR part 71.47 limits for shipping radioactive materials. This was not in accordance with procedure D 11 .7, section 6.10.6, exceeding 200 mremlhr on contact with the shipping container on an open transport. The container (Box 311677) was shipped from the Prairie Island facility and contained fuel sipping equipment.

Investigation Scope (As taken from the Charter):

The evaluation will determine the root cause of exceeding DOT shipping limitation s as required by 10 CFR 71.47.

The scope of the review will include an investigation of the methods used to detennine radiation levels of the components shipped, as well as methods for verifying dose rates on the exterior of the shipping container and the trailer. The investigation will also try to detennine the most likely contributor of the changing dose, where the material contributing to the high dose rates came from and why the dose rates changed.

AdditionaJly. the RCE will determine any organizational and industry weaknesses that contribute to the probabiUty of incurring transport issues related to radiation dose limits.

Problem:

On 10/31108, personnel at the Westinghouse facility in Waltz Mill. perfonning receipt surveys on a shipping container received from Prairie Island , disco vered a maximum reading of 2000 mRlhr on contact at the bottom of the container. This exceeded the IOCFR71 and 49CFRI73 limits for shipping radioactive material.

On Thursday (10/30/2008). a shipping container sent from Prairie Island was received by the Waltz Mill site. Shipping container 311677 contained fuel sipping equipment. On Friday (10/31/08) after unloading from the flat bed truck, a survey of the shipping container indicated the shipping container exceeded 200 mremlhr on contact. The maximum contact levels on the Shipping container were 1630 rnremlhr on contact. This level exceeded 49CFR 173 Department of Transportation (DOT) limits for shipping radioactive materials and also was not in accordance with Prairie Island procedure D 11.7, section 6. 10.6, exceeding 200 mremlhr on contact with a shipping container on an open transport.

This condition potentially existed from 10/29/08 through 10/3 1108.

Event Synopsis:

On 10/23/08 after fuel sipping was complete, fuel sipping equipment was removed from the spent fuel pool, decontaminated, surveyed and wrapped. On 10124/08, the loaded and closed shipping container was surveyed in the Aux Building drop area while on the transport trailer. A small spot on the bottom of the container was measured at 170 mremlhr with a Telepole in a location corresponding to the canister lid. On 10/29/08 Form retained in accordance with record retention schedule identified in FP-G-RM-O I.

QF-0433, Rev 2, (FG-PA-RCE-O I) RCE Report Template Page 6 of 81 inU11ediately before shipping the container, a radioactive waste shipping coordinator performed a confirmatory survey of the container surface dose rates to verify they were within DOT limits. This survey, performed on 10/29/08, located the spot corresponding to the lid and recorded a maximum contact dose rate of 150 rnremlhr.

The shipment of fuel sipping equipment was sent to Waltz Mill , Pennsylvania on 10/29/08 and arrived on 10130108. Personnel at the Westinghouse facility in Waltz Mill performed a receipt survey of the transport vehicle and found no dose rates in cxcess of DOT shipping limits. The following day (10/31/08), the shipping container was removed from the truck by forklift and a Westinghollse RP Technician performed a thorough survey of the shipping container. The survey recorded a maximum reading of 2000 mR/hr on contact at the bottom of the container with local instrumentation.

Westinghouse personnel identified this and notified Xcel Energy at that time. The maximum dose rate found on the bottom of the container with a Telepole (the instrument used to release the shipment) was 1630 mremlhr on contact at the bottom of the container.

==

Conclusions:==

Prairie Island did not have adequate barriers within the Radioactive Material Shipping Program (RMSP) to ensure DOT shipping limits are not exceeded. Several programmatic weaknesses aligned to allow the rad shipment to occur:

• The initial survey on the fuel sipping equipment was focused on personnel dose concerns and not obtaining a representative survey for rad shipment.

• The packaging of the equipment was not sufficient to ensure the materials would not shift during transport.

• The loading of the equipment was not observed by rad shipping personnel and was incorrect in consideration of discrete particles.

• The shipment of this type of material was not elevated as a priority to the site, because there is no formal guidance on what is significant in the Radioactive Material Shipping Program.

Correction of anyone of these failed barriers may have prevented this event from occurring. A robust RMSP would incorporate all of these actions to ensure radioactive material hipment issues do not occur. Relying on any single barrier (i.e., a good survey) to prevent rad shipping issues would not indicate a robust program.

The root causes of this event are centered on poor processes, oversight requirements, and procedure quality. None of these required the knowledgeable human involvement to ensu re successful completion of the shipping processes. The lack of multiple, mandatory, barriers led to the eventual failure and subsequent event. As a result, a singular failure of Human Performance barriers was not considered a major contributor to the overall failures that led to this event.

Radiological Safety Significance:

The location of the elevated radiation levels on the bollom of the box mitigated exposure to the general public to radiation levels in excess of regulatory limits. The shipping Form retained in accordance with record retention schedule identified in FP-G-RM-OI.

QF-0433. Rev 2. (FG-PA-RCE-OI) RCE Report Template Page 7 of81 container was not moved once placed on the trailer and the trailer was an exc lusive use shipment to the Waltz Mill site. The area between the container and the flatbed trailer was not accessible to the whole body of public or rad worker personnel during transport.

There was potential for dose rates in excess of regulatory limits in an accessible area of the container. If the contents of the container had shifted to the side of the box versus the bottom. the container dose rates in excess of regulatory limits would have been accessible and the potential for exposure to the public would have been elevated.

The shipping transport vehicl e survey readings (cab and trailer readings) were within regulatory limits and the movement of materials within the container would not have significantly affected the dose rates of the shipping transport vehicle.

There was no risk to the plant or plant workers.

Root Cause and Contributing Causes:

The root cau es have been identified as:

RCI. Radiation Protection and Chemistry procedures do not describe the methods required to successfully evaluate, package, and ship materials in accordance with 49CFR173 and IOCFR71.

RC2. The significance the site has assigned the Radioactive Material Shipping Program (RMSP) does not align with the potential adverse consequences.

The con tributing causes have been identified as:

CCI Industry Experience has not been effectively incorporated into the RMSP.

CC2 The training and certification programs for RP personnel who perform shipping related activities do not meet industry standards.

Inappropriate Actions:

Several Inappropriate actions were identified during the investigation :

IA#. I Workers did not package the fuel sipper cables to prevent shifting LAW DII.7. (see why staircase 2.0)

IA#.2 RWSC did not verify that the survey or packaging wa adequate for shipping.

(see why staircase 3.2.2)

IA#. 3 Shipping was not specifically addressed in WO 367253 as required by FP-RP-jPP-O I. step 5.5. (see why staircase 4.0)

Per the root cause guide. these inappropriate actions were evaluated to determine causal factors. These causal factors were grouped and further analyzed to determine the root and contributing causes.

Form retained in accordance with record retention schedule identified in FP-G-RM*O I.

QF-0433, Rev 2, (FG-PA-RCE-O J) RCE Report Template Page 8 of 81 Corrective Action Synopsis:

Corrective actions are focused on addressing the programmatic opportunities identified during the evaluation that identified the root and contributing causes.

The corrective actions will make appropriate changes to the RMSP shipping procedures to drive involvement of personnel to monitor activities that may elevate risk. Those activities are: the initial characterization of the equipment to be shipped, the wrapping of the equipment for transport, loading of the equipment in the shipping container, and an evaluation of survey differences between the container and vehicle survey results.

Several corrective actions have also been created to coordinate Radiation Protection Technician involvement in RMSP activities.

Changes are required for site procedures to ensure that proper levels of approval authority are required for successively higher levels of risk encountered in rad shipments. Rad Shipping program procedures will clearly define varying requirements for different levels of risk significant rad shipments. RP department procedures will contain guidance for handling discrete particles, particularly for equipment that will be shipped.

Additional changes will be made to the RMSP to ensure there are ties to the industry to encourage continuous review and improvement of the program and maintain indu try standards. The issue of discrete particles was a significant industry issue, as determined by the number of operating experience promulgated. Prairie Island did not allocate the time or effort to ensure the program was maintained to increasing standards.

A specialty task will be added to the RPT qualification program for field activities to ensure RMSP personnel have adequate focus to ensure sufficient barriers that prevent radioactive material shipment issues. Specific checks for adequate qualification for personnel involved in rad shipping evolutions have been included in the RMSP procedures.

Reports to External Agencies & the NSPM Sites:

Per 10 CFR 20.1906(d)(2), the reporting responsibility for a shippin g even t lies with the receiver of the shipment. In this case, the Westinghouse Radiation Safety Officer notified the State of Pennsy lvania Department of Environmental Protection (PADEP) and Southern Pines Trucking in accordance with 25 CFR 219.5 and 219.6 (Pennsylvania statutes), which incorporate 10 CFR 20.l906(d). informal communication with NRC Region m and Ule Resident Inspectors was also conducted.

An internal Operating Experience report was filed (I 1111/2008) as part of this event. A nuclear network message was promulgated via GAR 01158434.

Form retained in accordance with record retention schedule identified in FP-G-RM -O1.

QF-0433, Rev 2, (FG-PA-RCE-OI) RCE Report Template Page 9 of81 D. Event Narrative Event Narrative:

On Friday ( 10/3 1/2008), a radioactive shipment that arrived on J0/30/08 at the Westinghouse Waltz Mill facility was determined to have exceeded the 49CFRI73 DOT package dose rate limit of 200 mrernlhr on contact. After the shipping container was unloaded from the trailer (10/31/08), the maximum measured contact dose rate was 1630 mrem/hr on the underside of the container. Pre-shipment surveys conducted at Prairie Island had indicated a maximum contact dose rate of 170 mrem/hr, which implies that radiological material shifted inside the shipping container while en-route to Waltz Mill.

Approximately two weeks prior to the start of the 2R25 refuelin g outage (912/08), a request to add spent fuel assembly sipping activities to the outage scope (for the purpose of screening assemblies for future dry cask loading) was approved by the outage scope committee.

Performing this work during the outage was believed to have a cost savings associated with it because Westinghouse personnel would be on site and available to perform the work during an extended no-mode window. The station received a new (new design, non -radioactive) fuel sipping apparatus (9/ J 2/08) for use during the outage.

The sipping equipment was used during the 2R25 outage to test used fuel bundles for defects.

After this operation was complete ( 10/23/08), the equipment was removed from the spent fuel pool, decontaminated, surveyed and wrapped. The sliding, removable lid that forms the top of the sipping canister was decontaminated to a contact reading of 120 mrernlhr and 50 mrernlhr at 30 cm. It was wrapped and tagged with dose rate and contamination levels. The lid was placed in the bottom of the vendor-supplied shipping container (10/24/08). The wrapped canister was placed on installed cribbing inside the same shipping container and the container was closed and secured. The loaded shipping container was transferred to the transport trailer and surveyed while the trailer was in the Aux Building drop area. Prior to placing the container on the trailer (while still suspended), the entire bottom of the container was surveyed. During this survey, a small spot on the bottom of the container indicated 170 mrem/hr in a location corresponding to the canister lid. This was documented on a Caution Radioactive Materials Tag and placed on the container. The container was then set on the truck bed.

[mmediately before shipping the container (10/29/08), a RWSC performed a confirmatory survey of the container surface dose rates to verify they were within DOT limits. This survey located the spot corresponding to the lid and recorded a maximum contact dose rate of 150 mrern/hr. Both surveys of this spot were completed using a small dianleter probe. The shipment was released from Prairie Island on 10129/08 and arrived at Waltz Mill, Pennsylvania the next day.

Personnel at the Westinghouse facility in Waltz Mill performed a receipt survey of the transport vehicle and found no dose rates in excess of DOT shipping limits. The Oat bed trailer and shipping container were placed in an RCA. The following day (10/31/08), the shipping container was removed from the truck by forklift and a Westinghouse RP Technician performed a thorough survey of the shipping container. The survey recorded a Form retained in accordance with record retention schedule identified in FP-G-RM-O I.

QF-0433 , Rev 2, (FG-PA-RCE-OI) RCE Report Template Page 10 of81 maximum reading of 2000 mrem/hr on contact at the bottom of the container. Westinghouse personnel notified Xcel Energy at that time. The box was left in this area without opening (at Xce!'s request) until the Xcel fleet RPM and a Radiation Protection Technician traveled to the Westinghouse facility (11103/08) to gather data and to conduct an investigation. The maximum dose rate found on the bottom of the container with a Telepole (the instrument used to release the shipment) was 1630 mremlhr on contact at the bottom of the container.

Form retained in accordance with record retention schedule identified in FP-G-RM-Ol.

QF-0433. Rev 2. (FG-PA-RCE-OI) RCE Repon Template Page II of81 lll. Extent of Condition Assessment Extent of Condition The extent of condition is defined as material being shipped that exceed DOT shipping regulations. The condition of not meeting shipping requirements could apply to any material that is being shipped from the site that has the potential for containing radioactive material.

Currently there are no shipments of radioactive or hazardous materials in progress. A search of the CAP data base was performed to detennine if past problems have been identified during shipments. The search used AR origination date range of 1/112006 to 12/31/2008 (3 years) and used the following key words in the AR Subject and AR Description & Notes field: shipment. hazardous material. hazmat. DOT. tritium . asbestos, and PCB . The search results were reviewed looking for ARs related to shipping.

The following applicable CAPs were found:

ARO I058797 (10/3112006). Hazardous Material Shipment completed without required signature. Summary: NALCO delivered an incorrect product to PI. When the product was returned to NALCO, PI should have initiated hazardous waste shipping papers. Action initiated to provide DOT training. Training completed during April and May. 2007 and curriculum added to learning management system (LMS).

AROI078953 (02/23/2007). Radioactive shipment without packing slip. Summary:

Receiving Warehouse received a Radiological shipment without the proper paper work included. Individual took control of package and notified the RWSC. No corrective actions were taken .

AROI086930 (04/1012007). Improperly filled out sample shipment paperwork. Water samples are shipped off site for vendor analysis for tritium. Summary: A sample was inappropriately checked as being sent when it was not. Human performance error-inattention to detail was identified. This CAP was closed to trend, and no corrective actions were taken.

AROI056394 (10118/2006). Evaluate DOT HazMat training requirements for non-compliance. Determine who is required to receive DOT HazMat training per federal regulations. Summary of action completed: DOT hazardous waste training was provided to applicable Mechanical Maintenance personnel. Training was provided By Xcel Energy training Representative who specializes in environmental hazardous waste and DOT issues. Training was completed on 4117/07. 4/24/07. 5/1/07 and 5/8/07.

Form retained in accordance with record retention schedule identified in FP-G-RM-Ol.

QF-0433, Rev 2, (FG-PA-RCE-OI) RCE Report Template Page 12 of81 AROI065488 (12/04/2006), Transportation laws for tritium powered weapons sights.

Draft an attachment to SIP 4.3 in accordance with Fleet direction to ensure site compliance with Federal laws pertaining to the land vehicle transport and use of security weapons sights containing a tritium source. This Federal requirement is contained in Title 49 CFR 172, HAZMAT Transport. Closed to Fleet ARO 1070 I 41, NMC Compliance with 49CFR I72.42 1-424 & 173.H is in question. Action taken:

Procedure Revisions to address DOT Regulations for tritium transport.

AROI093013 (05117/2007), Return of Safety Related Batteries to Vendor Delayed.

Summary: Numerous delays occurred in shipment. CE was perfonned and one issue identified was lack of ownership to get the batteries hipped. There was no single point of contac!. The corrective action for this event included providing coaching to the departments involved.

The evaluation of extent of condition has determined there have been no findings of significance in other areas where materials are shipped in the past 3 years. The analysis does show an appropriate threshold for identifying shipping related issues in these other processes, therefore the extent of condition is limited to radioactive materials shipped using the RMSP.

Extent of Cause The extent of cause analysis determines if the root causes of this problem have impacted other plant processes, equipment or human performance. Five distinct areas are considered for extent of cause:

• Envirooment- Do the causes impact other work environments or locations?

• Equipment- Do the causes impact other equipment, systems or set of components?

• People - Do the causes impact other personnel (other than those involved) or other human performance issues?

• Organization - Do the causes impact other crews. departments or organizations?

• Process - Are there identical or similar processes or procedures that may be impacted by the causes?

The methods used are to compare in the following manner:

• Identical to Identical (same - same);

• Identical to Similar (same - similar);

Root Causes:

RCI. Radiation Protection and Chemistry procedures do not describe the methods required to successfully evaluate, package, and ship materials in accordance with 49CFR173 and 10CFR71.

RC2. The significance the site has assigned the Radioactive Material Shipping Program (RMSP) does not align with the potential adverse consequences.

Form retained in accordance with record retention schedule identified in FP-G-RM-OI.

QF-0433. Rev 2. (FG-PA-RCE-OI) RCE Report Template Page 13 of 81 Scope of the Extent of Cause The scope of the Extent of Cause for RCI includes RP shipping procedures and procedures that affect shipping such as the Hot Particle Program and procedures coveri ng shipping of all kinds of hazardous materials. This adequately addresses the Same-Same and Same-Similar guidelines for extent of cause. Additionally. RCI , procedures not sufficiently describing methods to achieve successful outcomes, potentially extends to all departments and processes on si te. The analysis of ite procedures beyond hazmat shipping and related RP procedures is limited to actual impacts of inadequate procedural guidance that rise to a level that results in a Root Cause Evaluation and that result in department-wide procedure improvement initiatives. The conclusions of this site-wide EOC are contained in an addendum at the end of this section . Supporting documents are listed in the Xl. References section of this report.

Environment - the work environment involved is not impacted by the process requirements or methods. and is not impacted by the priorities. Other work environments are not impacted by either cause. (084)

Equipment - Equipment was not identified as a significant condition so therefore was not evaluated in the extent of cause for either cause. (084)

People - Environmental has only a single individual with no dedicated backup at this time.

however they use Xcel Corporate Environmental team for peer checking. Warehouse has multiple people who arc qualified for loading and unloading. Chemistry. Security and Construction have multiple individuals who are trained to complete the tasks assigned for shipping per information obtained during interviews. Quality Assurance used to have people doing QC inspections on shipments (some were radioactive shipments) but this has been eliminated. The inspections completed by QC did not have any radiological function associated with them. (084)

Rule based space has people operating with procedures but the procedures are di sjointed or not prescriptive and lead people into knowledge based space where they have to interpret what is meant. This increases the chances of human performance errors. (084)

Organizations - Quality Assurance, Warehou se, Environmental. Chemistry. Security and Construction all were determined to be areas that may be involved in shipping materials that are subject to regulations. (084)

Processes - Thirteen procedures were evaluated and seven are not robust in their description of the methods required to successfully evaluate, package and ship material in accordance with requirements. (084)

Ouality Assurance QC1M-R-OI is no longer relevant. old procedure.

Conclusion:

Form retained in accordance with record retention schedule identified in FP-G-RM-O I.

QF-0433, Rev 2, (FG-PA-RCE-Ol) RCE Report Template Page 14 0f8 1 QCIM-R-Ol is active but there is no reference to this anywhere, no longer used, and was replaced by QATR. (085)

Warehouse Warehouse relies on an individual from Radiation Protection for rules and regulations regarding shipping items that may contain radioactive materials. Radioactive items have additional requirements from the DOT that are not part of warehouse personnel expertise.

Sending DOT Hazardous Material , (chemicals, lead, batteries, etc.) rely on individual from Environmental/Chemistry regarding requirements from DOT.

Loading and unloading materials requires drivers obtain Xcel provided DOT Hazmat training.

Shipping guidelines from the QA program are utilized (NQA I sub part B) for safety related parts. This is used mainly to protect the part itself from damage or moisture and metals. FP-SC-RSI-04 Material Return Receipt is utilized for when to use crating, pallets, protect from sharp edges.

Xcel provided DOT Hazardous shippers training and the DOT reference book as found on-line at Expressnet are utilized for information as well as loading and unloading requirements.

Conclusion:

FP-SC-RSI-04 Material Return Receipt procedure was determined to be adequate.

(087)

Environmental A corporate Environmental peer check is obtained when shipping and receiving hazardous materials. The corporate Environmental team wilJ check or filJ out paperwork. DOT demands training and refresher training every three years.

D14.5 - Hazardous and Non-Hazardous Material Storage, Disposal and Labeling Requirements, 014.8 - Regulated Waste Management and PINGP I400 - Checklist for Hazardous Material shipments.

These procedures need some improvements to make them more readily usable. A requisition has been sent to hire a contractor to re-write these procedures within the next quarter.

DOT rules are utilized on waste management and shipping compliance via an on-line manual as provided by Corporate Environmental group (used to be hard-copy manual, this was changed to on-line for ease of updating and reference.) DOT specities types Form retained in accordance with record retention schedule identified in FP-G-RM-O I.

QF-0433. Rev 2. (FG-PA-RCE-OI) RCE Report Template Page 15 of81 of containers to use and even if shifting or transporting problems occur. the shipment will be safe.

Conclusion:

014.5 and 014.8 were determined to be adequate with room for improvements as listed. PINGP 1400 is adequate but not currently referenced in any site procedures.

Chemistry Samples of septic tanks are sent via RPlP 4518 per IOCFR20 section 20.2003. This is a very spec ific procedure. easy to follow .

Technicians count samples for activity frequently . If the samples need to be sent out.

Chemistry personnel rely on individuals from Radiation Protection to receive and ship within requirements. Chemistry staff is not required to know these processes.

Occasionally Chemistry is required to transport large amounts of chemicals via personal vehicles. They would receive a briefing from an individual from Environmental/Chemistry as to OOT regulations. Most items. however. are smaller quantities and considered exempt quantity per OOT.

Most Chemistry technicians ship samples. Samples requested are done through work orders. All work orders now have form PTNGP 1409 to be completed to indicate if hazardous material or not. If individual does not know if item is hazardous. they are to contact Environmental/Chemistry. Lf not hazardous. then N/A is allowed on this sheet.

Proper labeling and packaging is specified through Xcel book or CFR requirements -

if unsure. go to Environmental/Chemistry individual or utilize Minneapolis Environmental group and on-line book.

Conclusion:

RPlP 4518 Septic Tank Sampling - Section 5.0 is adequate. (086)

No procedure was provided that shows requirements for transporting chemicals via personal vehicle. Recommend adding to plant access training program.

RPlP 3105. Preparing Oil. Fuel. and Special Samples for Shipment are adequate.

(091 )

PINGP 1409 is adequate. (092)

Security Safeguards information is explicit and detailed in regards to transporting as outlined in FP-S-SGI-O l.

Tritium transporting regulations had been violated and procedure was cbanged to now be more specific on how to transport and address that issue. Shipment containers for search. as well as ammunition and weapons transportation requirements are also well Form retained in accordance with record retention schedule identified in FP-G-RM-O I.

QF-0433, Rev 2, (FG-PA-RCE-O I) RCE Report Template Page 16 0f81 documented in Security procedure SEC 4.5. Any other items required to be transported/shipped are tumed over to the warehouse.

Conclusion:

SIP 4.5 Firearms Inventory, Inspection , Cleaning & Maintenance - Attachment 8 is prescriptive on how to transport Firearms, Ammunition and Tritium. (096)

FP-S-SGI-O I - Section 5.0 is prescriptive in how to identify, access via electronic and transport hard copies of Safeguards information. (095)

Construction Construction personnel utilize State of Minnesota guidelines MPSA , OSHA Guidelines and Pollution Control Guidelines. If sending out asbestos (usually once every three years), a licensed individual fill s out the manifest, and labels the dumpster. Licensing is done through the State of Minnesota and re-qualification is done annually.

As far as other hazardous material - construction is a supporting group that relies on Radiation Protection or Environmental/Chemistry groups as the ones who have the procedures and requirements to move/package within the required parameters.

Conclusion:

074 Site Asbestos, Section 15-18; is prescriptive with the exception that reference to document in 074 may not be correct. 074 references Xcel Energy Hazardous Materials Compliance Manual, Section 10 (page 28). (093) http://energysupply/envsvcsIESXWaste/wastedocslWaste_Manual.pdf, Waste Management Program ProcedurelWaste Management Guidance Manual - Section 3.2 was provided reference for Xcel Energy Hazardous Materials Compliance Manual (094)

Radiation Protection A review of RP programs found a deficiency in the risk significance detemlination portion of the work management program. The conditions that determine high ri sk for work planning in PINGP 1680; Task Risk Screening Worksheet (now updated to QF2010; Work Order Risk Screening Sheet) need to be adjusted to match management expectations.

Conclusion:

QF 2010 section Radiological Safety Screening for High Risk, requires adjustments for dose, dose rate, and contamination levels to meet management expectations.

The Prairie Island work management improvement effort (PRIDE) determined that risk management at the station required improvement. FP-WM-IRM-OI, "Integrated Risk Management" was developed to address this deficiency; the procedure was Form retained in accordance with record retention schedule identified in FP-G-RM-O l.

QF-0433. Rev 2. (FG-PA-RCE-O I) RCE Report Template Pagel70f81 approved on 5/812009. Station training was conducted on this process and all work order tasks are currently screened for risk (Nuclear. Industrial. Environmental.

Radiological. and Corporate). In addition. the 2009 HU lmprovement Plan - Risk Management was implemented at the beginning of 2009 to address risk management behaviors (CAPO 1177385).

Results of Extent of Cause Assessment:

Conclusion for RC I:

The goal of the extent of cause assessment for RCI was to determine if (program) procedures do not describe the methods required to successfully prepare and ship materials in accordance with applicable regulations and en ure management expectations for RP programs are incorporated into procedures.

The environment and equipment were detemlined to not be significant issues for this cause. The evaluation focused on people and processes but primarily focused on procedures. Six organizations were analyzed because they have processes that had same - similar correlations to the RMSP: Security. Warehouse. Quality Assurance.

Environmental. Chemistry. and Construction.

The review of RP programs found that the risk screening form did not contain the level of significance required by management expectations.

Overall. there were no significant conditions adverse to quality identified for extent of RC I. Four minor issues were identified and corrective actions have been initiated to address them .

Addendum A Focused Self Assessment entitled Transportation 950011nspection Preparation, July 20 - July 24. 2009 concluded that the original EOC for RCI was too narrowly focused . Therefore. additional evaluation of impacts to the site due to inadequate procedures and other written guidance was performed.

The evaluation included a review of all RCEs performed in the past 18 months ending 10114/2009. 14 RCEs have been completed in the past 18 months. Including this one. 6 RCEs identify procedure quality (i ncomplete or unclear information or direction) as either the root cause or a contributing cause (3 each). In all cases.

corrective actions were created and implemented to eliminate these issues per the CAP process. (D I 15)

DRUM reports. Department Excellence Plans. and Common Cause Evaluations covering the previous 18 months of performance in and Engineering. Operations. and Maintenance were reviewed for procedure quality issues. The Engineering Director.

Operations Manager. and Maintenance Manager were consulted during the evaluation. Engineering documents did not indicate noteworthy issues with procedure quality. The Operations department has experienced issues with procedure Form retained in accordance with record retention schedule identified in FP-G-RM-Ol.

QF-0433, Rev 2, (FG-PA-RCE-OI) RCE Report Template Page 180f81 quality, specifically associated with reactivity management, operability determinations, verification and validation, and staffmg. This issue has been captured in the Operations Department Excellence Plan for 2009 and tracked by CAP 011 17762,01 I 17746, 01 169711. There is an ongoing process to improve the detail in Maintenance procedures according to the Procedure Supervisor. (D 115)

Conclusion for RC2:

The assessment for RC2 was built around the statement: 'the significance the site has assigned the (department) program does not align with the potential adverse consequences. This bounds the analysis of same to similar.

To assess whether the program has 'significance,' the related shipping evolution was reviewed to determine if there were adequate procedures, if the processes were covered under work management processes, and the numbers and qualifications of personnel associated with the program. Once an assessment of the significance of the program was completed, the risk associated with tbe program was assessed through interviews and by review of the site and fleet risk procedures. An extent of cause would be confirmed by the combination of a significant risk to the facility AND a failure to provide adequate procedures, personnel and processes to control that risk.

Of the programs reviewed, the Quality Assurance, Construction, and Warehouse groups provide services for other programs. These services are basic services that are controlled via the target program procedures. There wcre no conditions adverse to quality identified in these program groups.

Overall, there were no identified or potential significant conditions adverse to quality identified for extent of cause two.

The Chemistry, Environmental, and Security groups do have evolutions that are risk significant. These shipping evolutions are controlled by persons that are trained or qualified to perform these evolutions llsing established procedures. For the Chemistry group, these evolutions are usually controlled within the work control process.

The RP work management program did not have the proper level of risk identified for screening work as high risk. The site work management improvement effort implemented FP-WM-IRM-OI to address risk assessment deficiencie in work planning at the site. As review of the risk screening form (QF-20 I0) associated with FP-WM -IRM -OI indicated that additional improvements were necessary to incorporate the proper risk assessment for radioactive material shipments. A corrective action to update QF 2010 was initiated.

Form retained in accordance with record retention schedule identified in FP-G-RM -Ol.

QF-0433, Rev 2, (FG-PA-RCE-O I) RCE Report Template Page 19 of8 I IV. Previous Similar Events:

AROOO52837 (06/200 I)

On 6/22/0 I PrNGP shipped 5 shipping containers of contaminated lead blankets to Kewaunee Nuclear power plant. Upon arrival the Rad Protection techs discovered one shipping container read 1.8 mremlhr on contact instead of the <0.5 mremlhr as initially surveyed at PrNGP and as required per DOT classification. All investigation at Kewaunee found one lead blanket (in the shipping container in question) which had a fixed contact dose of 4-5 mrem/hr. The blanket(s) had shifted in transit. The comer of the shipping container which indicated 1.8 mremlhr was the comer that the blanket with the contact reading of 4-5 mremlhr was found. Kewaunee concluded that the blanket shifted in transit.

Corrective actions included placing higher scrutiny on item >80% of DOT shipping limits, coaching workers on higher sensitivity to shifting items, more over-sight to the loading of "hot" equipment and utilizing a higher DOT classification if container is questionable.

This issue occurred in 200 I. This issue was poorly evaluated as an ACE and actions assigned were not adequate to prevent recurrence. The corrective action program has been modified to be more robust since this issue has occurred, including a more robust ACE guide, qualifications for ACE report writing, and requirements for ACE grading through supervision. In addition, improvements to the corrective action program at PI since 200 I would ensure this previous issue would have been a root cause evaluation which would have produced recurrence control actions, instead of an ACE. None of the corrective actions stated in the ACE were incorporated into procedures. This was a missed opportunity to improve the RMSP.

ARO 1088559 (4/19/2007)

A box containing spare ParlS for reactivity computers that was supposed to be shipped to Point Beach in December 2006 could not be found. A thorough search of numerous site locations was conducted to locate the missing box. Point Beach was contacted, and they had no record of ever receiving the box. Couriers typically employed by the si te were contacted and their records were reviewed with nothing relevant found. No further evaluation was conducted to determine how this box went missing, and no corrective actions were implemented to prevent it from happening again.

ARO 1138552 (5/2212008)

Certain analyses for efnuent releases are performed off-site. When samples were shipped to the vendor in May of 2008, the vendor reported that the box arrived crushed. This resulted in one of the samples being compromised. The RWSC stated that the samples and box were properly packaged and in good condition when they left the site. The damage to the box appears to have occurred when in the possession of the shipping company. Corrective action was to purchase a more robust shipping container.

Form retained in accordance with record retention schedule identified in FP-G-RM-OI .

QF-0433, Rev 2, (FG-PA-RCE-OI) RCE Report Template Page 20 ofSI AR01154944 (1011 IlOS)

During 2R25, a worker alarmed the portal monitor in the guardhouse as he was leaving for the day. Upon investigation he was found to have a 2600 ccpm particle on the outside of his right sock. It was believe to have come from the workers cloth shoe covers that he was wearing while working in tbe SFP area. Subsequent surveys of the SFP area, the dress out area, and the Westinghouse trailer (where the worker changed out of his modesty clothing) detected no further particles in any of the areas.

The recommended solution to this issue was to no longer continue the use of cloth anti-contamination clothing.

AROl155971 (10/17/0S)

A worker was working on sand plug installation during 2R25, had a 2S00 ccpm particle on his foreann, below the elbow. The worker had been in the cavity to assist with sand plug installation and moving the old sand plugs that were previously wrapped from the north side of the SFP to the south side of the SFP. Actions taken after this event included decontamination of worker and surveys conducted in work area. Two particles were found during the survey, one at 600 ccpm and one at 5000 ccpm. Both particles were found on tools/equipment used in the job.

ARO 115SS79 (J Jl12/0S) Note: This event occurred during the same outage and after the initial event.

During a pre shipment survey of a trash sea land container, dose rates greater than those allowed for shipment were found. Contact dose rates of 220 mremlhr were found on the bottom of the container which exceeds the 200 mremlhr limit. This was found prior to the container leaving the RCA. It was determined that lack of over-sight during rad waste loading activities contributed to this occurrence. Corrective actions for this issue include reloading of the sea land container and performance of another survey to ensure that aJJ shipping limits are not exceeded.

In these cases, workers reacted to situations based on indicated initial parameters.

Appropriate immediate and supplemental actions were taken to rectify the conditions.

In the above cases of discrete particles, many lower activity particles were found during outage 2R25. Corrective actions were effective to correct the condition. Discrete particles are routinely found in radiological areas during outages. None of the discrete particles were significant enough to warrant TEDE dose concerns.

Form retained in accordance with record retention schedule identified in FP-G-RM-O I.

QF-0433, Rev 2, (FG-PA-RCE-OI) RCE Report Template Page210f81 Y. Operating Experience:

o Internal Operating Experience-A moderate number of similar shipping events have occurred within the industry (see Operating Experience), but an issue of similar potential significance has not occurred with a shipment from Prairie Island. A 200 I rad shipping issue of lesser significance is identified in the previous similar events section.

The following reviews are from significant events over the last 6 years. The areas that will be analyzed are:

I) a lack of oversight of radiation protection evolutions;

2) use of risk significance to establish requirements for supervisory oversight of radiological issues;

3) A lack of planning that could have prevented radiological issues from occurring.

Lack of oversight of radiation protection evolutions:

In the Radiological Protection (RP) department, a number of issues have been identified for which a lack of appropriate oversight was identified as the primary contributor:

• CR 200 11095 SI 9-2 particle

• CAP 1075188 workers may have entered area without coverage

• CAP 1027384 moving a HRA gate during an evolution These evolutions were either caused by or had a major contribution to the event from a lack of oversight of the radiation protection group during the process.

Lack of risk significance process to determine proper supervisory oversight for radiological issues.

There were several significant events in the radiological protection group that were either caused or had a major contribution to the event from a lack of supervisory oversight. The events are:

• RCE 1099775 HRA, LHRA, VHRA controls

• RCE 1114156 Sump C Key

• CAP 1032220 Improper locking of YHRA

• CAP 1083810 Key control In each of these issues, the recurring theme is a lack of understanding of the significance of the actions being taken. In each of these cases, the use of risk based significance process to determine appropriate involvement would have ensured adequate direction to prevent the issue from occurring. Such controls were not in place. This is a significant issue and corrective actions implemented by this root cause analysis address risk assessment.

Additionally. there are supervisory oversight aspects that have been recently identified across the organization. Tbere are a number of recent examples of issues resulting from lack of oversight (including lack of vendor oversight), including:

o Portable diesel fire pump found with improper settings to support B.5.b strategies (vendor oversight)

Form retained in accordance with record retention schedule identified in FP-G-RM-O I.

QF-0433, Rev 2, (FG-PA-RCE-OI) RCE Report Template Page 22 of81 o Turbine driven auxiliary feed water pump bearing installation error.

o Neutron flux monitor Raychem splice installation errors.

o Control rod damaged during movement.

Although vendor oversight was identified as a causal factor in thi s root cause, it was not significant because it was determined the lack of oversight of the rad shipping group was the primary factor, not that vendors were involved.

Lack of planning leading to radiological issues.

A lack of planning has been identified at Prairie Island as a gap to Excellence.

Generically, the work management process has been identified as a major deficiency.

Several gaps have been identified and a project team (Work Management Lnitiative) is chartered to resolve these issues. From the perspective of radiation protection, a lack of planning, specifically ALARA planning, has been identified. Related to this issue are several CAPs that have identified inappropriate planning.

• CR 200J 1095 S19-2

• CAP 1027653 lack of fuel failure strategy

• CAP I 131673 resin sluice issues In the last cap li sted above, it was determined there were very few rad shipping evolutions carried in the work management process. Since the ALARA planning function is initiated as part of work order review, there is therefore very litLie planning associated with rad shipping. This has been identified as a separate issue (from the root cause charter) regarding lack of planning when removing the sipping canister lid from the spent fuel pool and was not evaluated here. There is ample evidence that there is a lack of ALARA planning for rad shipping evolutions and that the ALARA planning function at Prairie Island is minimal.

ExternalOE A search was performed on the INPO data base for industry events related to rad shippin g discrepancies. There are many causes associated with radiological shipping deficiencies.

The following is a summary of related industry events:

App. OE Date Site Description Discrete particle moved, contaminated X IN 88-101 12/28/1988 various equipment moved.

Inappropriate survey extent of X OE5492 7/3111992 Quad Cities Underwater Shear Cutter (USC)

Peach OEI1870 1/31/2001 Bottom 3 Neutron source shifted during shipping Sources improperly controlled during OEI1952 2/2812001 TMI I transport Form retained in accordance with record retention schedule identified in FP-G-RM-O I.

QF-0433, Rev 2, (FG-PA-RCE-OI) RCE Report Template Page 23 of 81 App. OE Date Site Description DOT shipment with contact dose rate of 500 mremlhr. Mop heads shifted in X OEI3815 5/20/2002 Ft Calhoun transit , incomplete survey.

OE14892 10/28/2002 Clinton Shippin.e. container was contaminated.

Shipping container had a hole in it.

Nine Mile Loads within container were not braced OE15728 311312003 Point 2 and had moved . No limits exceeded Nine Mile 55 gallon drums not surveyed on the X OE 171 36 10/23/2003 Point bottom.

Duratek shipped equipment at X OE 17709 2/2/2004 LaSalle 200mremlhr to laSalle Duane Cask received at DAEC in excess of OEI7741 2/6/2004 Arnold DOT receipt contamination level s Vacuum cleaner debris was stored near edge of container that exceeded DOT X OE 17831 2/2312004 DC Cook shipping limits OEI9437 11/312004 Davis Besse Contamination on exterior of HJCs ICI cutter had high external to container dose limits but did NOT exceed DOT X OE 20225 311912005 Ft Calhoun shipping criteria licensees changing the construction of IN 05- 10 4113/2005 various boxes Resin sluiced to liner not rated for dose OE 21469 7/2212005 Palisades rates from resin.

Vermont Advance Crusher Shearer (ACS) shipped Yankee and in excess of DOT limits due to discrete X OE23408 1011112006 Susquehanna particle and small particle movement Limited Quantity shipment in excess of San Onofre 0.5 mremlhr contact dose rates for and Fort shipment of lead blankets (max reading X OE 24029 12/812006 Calhoun 3.4 mremlhr.

Discrete particle left in bottom of TN-LaSalle and RAM cask caused readings of 7 Remlhr X OE 25642 8/22/2007 Barnwell in the back of the cask.

Ultrasonic fuel cleaning equipment was Watts Bar shipped with a contact dose reading in X OE 26644 3/312008 and AREVA excess of DOT limits Pilgrim and Vermont Yankee received package that Vermont exceeded DOT limits due to shifting of X OE27653 10/3/2008 Yankee contents Form retained in accordance with record retention schedule identified in FP-G-RM-Ol.

QF-0433, Rev 2, (FG-PA-RCE-OI) RCE Report Template Page 24 of 81 There are several recurring themes evident from the review of the external operating experience:

• Surveys to verify shipping requirements were met are not adequate prior to shipping.

• Materials used to handle irradiated items do not have adequate focus, oversight, or controls to ensure DOT shipping limits are met when the equipment is shipped.

• The RMSP of any site is responsible for ensuring the contents of the container are adequately restrained to prevent movement or redistribution of activity within a container during normal shipping evolutions.

• Shipping containers used to ship materials with risk significant activity must be designed and loaded to minimize the potential for exceeding DOT limits.

• There are three generic ways DOT limits are exceeded during shipping evolutions:

the equipment, shielding, or a discrete particle shift during transport.

• Procedure~ are generally not robust enough to prevent rad shipping issues.

The e points from industry OE were used to evaluate for potential issues for this evaluation at Prairie Island.

As part of this evaluation, the OE program was reviewed to determine if the program is effective. In accordance with the OE Program guidance, OE items can be dispositioned by distributing for information only, evaluation required, training request, or no action required.

The OE items distributed to Radiation Protection during the period from 11112007 to 12/3112008 included INPO Operating Experience (OE) reports, Signilieant Event Notifications (SEN), Significant Event Reports (SER), Operating Experience Digests (OED),

and Radiological Protection Digest. During this period 207 OE items were distributed Radiation Protection. During this same time period 46 OE items were evaluated by Radiation Protection.

There were numerous opportunities following the release of IN 88-10 1 (Shipment of Contaminated Equipment between Nuclear Power Stations) for the site to respond to industry trends associated with radiological material shipments containing discrete particles. For example, in the five year period prior to the subject event, each of the applicable OEs listed below was distributed to site RP personnel for review:

OE /I Date Site Description Duratek shipped equipment at 200mrem/hr to OE17709 21212004 LaSalle laSalle Vacuum cleaner debris was stored near edge of OE17B31 212312004 DC Cook container that exceeded DOT shipping limits Resin sluiced to liner not rated for dose rates from OE21469 7/2212005 Palisades resin.

Vermont Advance Crusher Shearer (ACS) shipped In excess OE2340B 10/11/2006 Yankee and of DOT limits due to discrete particle and small Susquehanna particle movement Form retained in accordance with record retention schedule identified in FP-G-RM-OI.

QF-0433 , Rev 2, (FG-PA-RCE-OI ) RCE Report Template Page 25 of 81 OEiI Date Site Description Limited Quantity shipment in excess of 0.5 mremlhr San Onofre and OE24029 12/8/2006 contact dose rates for shipment of lead blankets Fort Calhoun (max reading 3.4 mremihr.

LaSalle and Discrete particle left In bottom of TN-RAM cask OE25642 812212007 Barnwell caused readings of 7 Remihr in the back of the cask .

Watts Bar and Ultrasonic fuel cleaning equipment was shipped with OE26644 3/3/2008 AREVA a contact dose reading in excess of DOT limits Pilgrim and Vermont Yankee received package that exceeded OE27653 10/3/2008 Vermont DOT limits due to shifting of contents (OE not Yankee received until after 10/30108)

These articles were distributed for information only and were not formally evaluated.

The RMSP was evaluated for how Operating Experience was dispositioned over a five year period. The results are shown in the table above. The evaluation of the operating experience was found to be unsatisfactory for the RMSP. As extent of condition, the Operating Experience for the Radiation Protection and Chemistry department was evaluated for a two year period. A total of 56 OE evaluations were performed from 1011/06 to 1011/08. Pursuant to the evaluations, actions were initiated to enhance or alter plant practices in 15 cases, recommendations for enhancements in 3 cases and no actions necessary in 38 cases (OE did not apply or the correct.ive actions were already contained in plant procedures/pract.ices).

Based on this review, the disposition of operating experience for the radiat.ion protection and chemistry department (other than the RMSP) was found to be satisfactory.

Form retained in accordance with record retention schedule iden tified in FP-G-RM-O I.

QF-0433. Rev 2. (FG-PA-RCE-OI ) RCE Report Template Page 26 of81 VI. Radiological Safety Significance In thi event. a discrete particle was embedded in a vacuum can ister lid rigging cable where it was not initially detected. In addition. the cables were oriented such that transport surveys did not reveal the discrete particle. This equipment shifted after leaving Prairie Island and before the shipping container was surveyed at Waltz Mill. When the receipt survey was conducted by Waltz MiJl personnel. maximum contact dose rate readings on the external of the shipping container had increased from 170 mrem/hr as measured at Prairie Island to 1630 mrem/hr. This maximum contact reading was located on the bottom of the container. and was identified when the container was lifted off the trailer inside the radiologically controlled area at Waltz Mill.

Subsequent investigation determined the elevated contact readings were the result of a discrete particle fixed to a coated cable in the shipment. The cable containing the discrete particle was a part of a bundle of cables that had shifted during Shipment. positioning the area of the cable where the discrete particle was located near the bottom of the shipping container. Contact dose rates with the bottom of the trailer as found at Waltz Mill were 80 mremlhr. and similar to the trailer bottom maximum contact reading from the Prairie Island pre-transport survey. This value was within acceptable limits when the tractor and trailer were initially surveyed on arrival at Waltz Mill. and met DOT vehicle dose rate requirements.

Trailer Configuration and Dose Rates I I I I

\ Trailer "L J

!&e.~nd

@ Conlact dose ralcs

• PI The location of the elevated radiation levels on the bottom of the box restricted exposure to the general public to radiation levels in excess of regulatory limits during transportation between Prairie Island and Waltz Mill. The shipping container was not repositioned on the trailer or removed while in transit and the trailer was an exclusive use shipment to the Waltz Mill. PA site. The truck was stopped for a maximum total of 5.75 Form retained in accordance with record retention schedule identified in FP-G-RM-O I.

QF-0433, Rev 2, (FG-PA-RCE-OI) RCE Report Template Page 27 of 81 hours9.375e-4 days <br />0.0225 hours <br />1.339286e-4 weeks <br />3.08205e-5 months <br /> during the trip. IL is highly improbable that any member of the public could gain access to that location, assuming normal conditions of transport, because no member of the public could have reasonably located a portion of their whole body between the container and the trailer without moving the container. The shifting of the contents repositioned the do e producing discrete particle to the bottom of the container at a location that was not readily accessible for whole body dose.

The elevated dose on the bottom of the container, and subsequenLly the dose producing discrete particle was found during the entry surveys at Waltz Mill. Waltz Mill has an established radioactive material program with multiple barriers to prevent workers from being ex.posed to the dose from the discrete particle. The shipping documentation survey prompted a thorough receipt survey which alerted the workers at Waltz Mill of the di screte particle dose concern.

For radiation workers handling the package, the choice of open versus closed transport is not significant because the per onnel handling the container would need access to the container whether it was open or closed transport.

In consideration of dose to the general public, the use of closed transport would have been an additional barrier to prevent undue exposure.

Potential Safety Significance - Other Possible Configurations Note: Thirty centimeters (i.e., one foot) is the regulatory standard for measuring whole body exposure rates (per 10CFR 20.1 (03 ), and whole body ex.posure is the quantity of interest for radiological risk.

Under worst case conditions, Shifting of the material within the container could have resulted in the discrete particle coming in contact with an exposed, accessible portion of the container and producing a dose rate for potential public exposure. The highest dose rate thirty centimeters from the 1630 mremlhr contact reading on the container was 89 mremlhr measured with an E-600 instrument. This spot was characterized by Waltz Mill as "very small". In addition, the maximum two meter reading from the transport read 0.5 mremlhr. During the investigation , characterization of the particle (apart from other radioactive material in the box) showed maximum dose rates of thirty mremlhr at thirty centimeters. Therefore, 89 mremlhr at30 centimeters will be conservatively app lied as the maximum potential whole body dose rate possible if the particle along with other material in the box relocated to an accessible location on the container.

A dose rate of about 89 mremlbr at thirty centimeters from all surfaces of a package that is shipped in accordance with DOT requirements is possible. For consideration of possible dose rates from a legal shipment, a 55 gallon drum with a composite density of 2.35 gjcc and with an activity of 93.5 millicuries of Co-60 will yield calculated dose rates of 200 mrem/hr on contact, 88 mremlhr at thirty centimeters from the side, and six mremlhr at two meters. Therefore, whole body dose rates on legal shipmenL~ can pose Form retained in accordance with record retention schedule identified in FP-G-RM-O I.

QF-0433, Rev 2, (FG-PA-RCE-O I ) RCE Report Template Page 28 of81 larger exposu re risks to the general public than this actual shipment or the postulated case where the particle is located in an accessible area.

The highest contact dose rate of 1630 mremlhr is about eight times hi gher than alJowed by DOT regulation. Radiation workers involved in a post accident response, or in handling of the container upon receipt of the shipment, are adequately trained and equipped to handle a hipment of this type.

The choice of open versus closed transport in the analysis of potential exposure is significant for consideration of exposure to the general public because a closed transport would have provided a sufficient barrier to prevent exposure of the public to dose rates in excess of 49 CFR limits on contact with the package. Personnel handling the container would have access to the container whether the truck was open or closed transport.

Conclusions In the actual event, the dose potential was limited to areas on the bottom of the container at a location that was not readily accessible for whole body dose; therefore, it is highly improbable that any member of the public could gain access to thaI location, assuming normal conditions of transport. The possibility that a member of the public received a whole body dose above a small fraction of the regulatory limit of 25 mrem (40CFR 190) is minimal.

Prairie Island realizes that the following potentials may have existed under worst case circumstances:

I. A potential existed for the material to re-locate to an accessible location on the container.

2. In this configuration, the potential whole body do e rate is bounded by the do e rates that are possible on legal shipments. Therefore, the potential that a member of the public would have received a radiation dose above the doses that are normally incident to transportation of radioactive material is minimal.

3. Waltz Mill has adequately trained personnel to prevent workers from being exposed to the dose from the discrete particle. The shipping documentation survey was adequate to alert tbe workers at Waltz Mill of the discrete particle and prompt a thorough receipt survey.

4. The public relies on the licensee to safely package radioactive materials. This event could have resulted in a significant erosion of public trust.

Evaluation of Safety Culture Impacts As part of !.his evaluation, safety culture impacts were assessed per QF-0436 (Attachment

7. The following significant issues were identified:

Form retained in accordance with record retention schedu le identified in FP-G-RM-O I.

QF-0433. Rev 2. (FG-PA- RCE-O I) RCE Report Template Page 29 of81

• HU - (H.l) Decision Making - The si te did not have a method for detennining ri sk significance of events related to shipping of radioactive material.

Assumptions regarding the adequacy of the radiation survey and contai ner packing technique were not conservative. When the original equipntent survey indicated 120 mremlhr, and the subsequent container su rvey indicated 170 mrem/hr, the opportunity to validate the integrity of the packaging was missed.

• HU - (0.2) Resources - Procedures are not adequate. Training is required for RP technicians performing RMSP work. A qualification program will be implemented.

• HU - (0.3) Work Control- RMSP activities are usually completed outside of the work management process. Shipping tasks and the risks associated with shipping are frequentJy not addressed in work packages. RP technicians provid ing job coverage for decontamination are not aware of rad waste shipping requirements with respect to discrete particle issues.

• HU - (0.4) Work Practices - Inadequate oversight (RMSP and supervisors) during packaging, surveying and crating evolutions. Some of the behaviors that contributed to this event do not support excellence in human performance.

• PI&R - (P.2) Operating Experience - OE is reviewed but some issues identified in OE are not evaluated nor are corrective actions properly implemented. Relevant changes to station processes, procedures, equipment and training programs are not effectively implemented.

• Pl&R - (P.3) Self-Assessment - Assessments are only included as part of the overall RP program itself. Tbe RMSP needs a separate requirement for assessments, based on program risk exposure, in order to be more self-critical.

• OTH - (0.2) Continuous Learning Environment - Adequate training has not been provided to ensure personnel performing RMSP duties have the required technical competency.

Safety Conscious Work Environment (SCWE)

A review of Safety Culture lmpacts was completed using QF-0436 (Attachment 7). There were no SCWE issues identified as part of this evaluation. There was no evidence of employees not rai sing safety concerns relevant to this event. There was no evidence of a chilled environment that might preclude workers from raising safety concerns related to rad shipments. This was concluded based on the results of interviews conducted as a part of this evaluation.

The root cause has identified and assigned corrective actions for the safety culture issues identified above. For extent of condition evaluation of these issues, CAP I 161675 has been written and submitted to CAP screening for evaluation and assignment.

Fonn retained in accordance with record retention schedule identified in FP-G-RM-O I.

QF-0433, Rev 2, (FG-PA-RCE-O I) RCE Report Template Page 30 of81 VIl. Reports to External Agencies & the NSPM Sites Per 10 CFR 20.1906(d) (2), the reporting responsibiHty for a shipping event lies with the receiver of the shipment. In this case, the Westinghouse Radiation Safety Officer notified the State of Pennsylvania Department of Environmental Protection (PADEP) and Southern Pines Trucking in accordance with 25 CFR 219.5 and 2 19.6 (Pennsylvania statutes), which incorporate 10 CFR 20. 1906(d). informal communication with NRC Region ill and the Residentlnspectors was also conducted.

An internal Operating Experience report was filed ( 1111112008) as part of this event. A nuclear network message was promulgated via GAR 0 I 158434.

Form retained in accordance with record retention schedule identified in FP-G-RM-OI .