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Abnormal Occurrence 50-289/75-36:on 751019,auxiliary Operator Failed to Obtain Radiation Work Permit & Carry Monitoring Device.Caused by Improper Administrative Procedures
	ML19210A202
Person / Time
Site:	Three Mile Island
Issue date:	10/29/1975
From:	Arnold R; METROPOLITAN EDISON CO.
To:	;
References
	GQL-1655, NUDOCS 7910240921
	Download: ML19210A202 (4)
	v • d • e

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PCCT CFFICE BOX 542 READING. PENNSYLVANI A 19603 - [ ?,, TELEPHONE 215 - 929-3601

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                                                                          -]'$  Cc.tober 29, 1975
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Dear Sir:

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e*'/ Decket No. 50-289 Operating License No. DFR-50 In accordance with the Technical Specificatiens of our Three Mile Island Nuclear Station Unit 1 (T'4I-1), we are reporting the folleving abner =al cecurrence. (1) Report Number: A0 50-289/75-36 (2a) Report Date: October 29, 1975 (2b) Occurrence Date: October 19, 1975 (3) Facility: Three Mile Island Nuclear Station Unit 1 (h) Identification of Cccurrence:

Title:

Failure of an auxiliary operator to obtain a Radiation ' Jerk Permit and carry a radiation monitoring device upon entrance to a High Radiation Area.

                        ?,fTe :   An abnormal occurrence as defined by the Technical Specificaticns ,

paragraph 1.8g, in that an auxiliary operater did not cbtain a Radiatien '4crk Pemit nor carry a radiatien =cnitoring device which continuously indicates the radiatica dese rate upon entrance to a High Radiation Area, which constitutes a viclation of Technical Specificatien 6.6.2.a. (5) Cendition Prior to Occurrence: Pcver: Core: 0% Elec.- 0 6 RC Flev: 139 x 10 lb/hr. RC Pressure: 2155 psig ]476 219 '

                                                                                                                                                  'l 12601

RC Te=p. 535 F PR1R Level: 120" PFZR Temp.: 650CF (6) Description of Cccurrence: On October 19, 1975, an auxiliary cperator was ordered to isolate, vent, and drain the Makeup and Purification Syste='s Prefilter MU-F-2A for filter replacement. The auxiliary operater was infor=ed that a Radiation Werk Per=it was issued for this jcb and that it shculd be confirmed in the Health Physics Laboratory and the applicable precedures folleved. Upon arrival at the Health Physics Laboratcry, the auxiliary operator observed that no health physics personnel were in the area. Having kncvledge that a Standing Rad J on Werk Permit existed for the verk area, the auxiliary operator u _ . ed to proceed with the venting, draining, and tagging operation withcut dis .assing it with the health physics personnel. The auxiliary operater assumed that the levels of radiation shewn en the Standing Eadiation Work Per=it covered the area that centained the filter as well as the valve alley. The permit only covered the valve alley. Aft r ec=pleting the assign =ent, the auxiliary operator observed an off scale read;ng on his self-reading dosimeter. The ruxiliary operator locked the area and notified the Shift Supervisor, who instructed the Radiatien Chemistry Technic 6 to evaluate the auxiliary operator's Ther=oluminescent Dosimeter (TLD). A reading of 1260 =re: (Whole Eody G9mmn) vas confirmed. Further, it should be noted that the individual's filn badge indicated a dese ef 1910

      = rem + 382 and the TLD reading is censidered to be =cre accurate at 1260 + 126 mrem.

Within one hcur of the incident, the Unit Superintendent held a meeting with the Radiatien Protection Supervisor and all the individuals involved to deter =ine the cause of the high expcsure. An investigating ec==ittee was convened by the Unit Superviser to investigate the circumstances surrounding the incident and recettend appropriate ccrrective actions to preclude future occurrences. (7) Designation of Apparent Cause of Occurrence: The cause of this occurrence has been dete=nined to be persennel/ procedure in that the prcper Administrative and i=plementing procedures were not folleved to perfor= the above described operatien. Additionally, the requirement for a radiation =cnitoring device which continucusly indicates the radiaticn dese rate in the area was not fulfilled. (8) Analysis of Cecurrence: It has been determined that this cccurrence did not constitute a threat to the health and safety of the public in that only the subject auxiliary operater was involved, and his exposure was less than 3 re=/ calendar quarter.

                                                                          \476 720   -

_1 ~ . (9) Ccrrective Action: In additien to the i==ediate action described above, long term corrective acticns are as follevs:

a. Precedural changes have been initiated to increase Aininistrative centrols fcr entry into areas greater than 1000 mB/hr.

b. Installation of a vindev in the locker docr of the Makeup & Purification Prefilter Valve Alley to eliminate entry into ares for routine shift checks vill be evaluated.

c. The installatien of the filters and piping vill be reviewed to determine if external manual operators can be installed on the drain valves of MU-F2A and MU-F23 (Makeup and Purificatien Syste= Prefilters),

d. Additional training vill be conducted for all persennel in the areas of Radiatien Work Permits and Administrative Centrols for entry into areas greater than 1000 mB/hr.

e. Procedure changes will be initiated to clearly state tnat dose rate indicating instruments must be carried in all areas in which radiation levels exceed 100 mB/hr .

f. Areas with radiation levels greater than 100 nB/hr. Will be posted with signs indicating the requirements to carry dose rate indicating instruments upon entry.

(10) Failure Data: Not applicable. Similar Occurrences: Ncne Sincerely, 0

                                                'i R. C / Arnold Vice President ECA:JMC:tas cc: Office of Inspection and Enforcement, Region 1 File:   20.1.1 / 7.7.3.5.1 1476 221}}

ML19210A202

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