ML20126F105

Discusses 921207 Enforcement Conference Re Unplanned Release of Am-241 Caused by Cutting Source Holder on 920922 & Loss of Control of 5.4 Ci Americium Source.Nrc Continuing to Review Issues to Determine Appropriate Enforcement Action

ML20126F105
Person / Time
Site:	Brunswick
Issue date:	12/11/1992
From:	Stohr J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
To:	Watson R CAROLINA POWER & LIGHT CO.
References
EA-92-217, NUDOCS 9212300111
Download: ML20126F105 (27)

Text

}iC DEC111992 Docket Nos. 50-325, 50-324 License Nos. DPR-71, DPR-62 EA 92-217 Carolina Power and Light Company ATTN: Mr. R. A. Watson Senior Vice President Nuclear Generation P. O. Box 1551 Raleigh, NC 27602 Gentlemen:

SUBJECT:

ENFORCEMENT CONFERENCE

SUMMARY

(NRC INSPECTION REPORT NOS. 50-325/92-32 AND 50-324/92-32)

This letter refers to the Enforcement Conference held at our request on December 7, 1992. This meeting concerned activities authorized for your Brunswick facility. The issues discussed at the conference related to the unplanned release of Americium-241 caused by cutting a source holder on September 22, 1992, and loss of control of the 5.4 Ci Americium source. A-list of conference attendees and a copy of your handouts are enclosed. We are continuing our review of these issues to determine the appropriate enforcement action.

in accordance with Section 2.790 of the NRC's " Rules of Practice," Part 2, Title 10, Code of Federal- Regulations, a copy of this letter and its enclosures will be placed in the NRC Public Document Room.

Should you have any questions concerning this matter, please contact us.

Sincerely, 1 i J. Philip Stohr, Director Division of Radiation Safety and Safeguards

Enclosures:

(See Page 2) l$k2]go 00 1

(

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h DEC111992 ,

Carolina Power and Light Company 2

Enclosures:

1. List of Attendees

2. Licensee Handouts ,

ccw/encls:

R. E. Morgan, Manager Brunswick Huclear Project P. O. Box 10429 Southport, NC 28461 H. Ray Starling Vice President - Legal Department Carolina Power and Light Co.

P. O. Box 1551 Raleigh, NC 27602 Kelly Holden Board of Commissioners P. O. Box 249 Bolivia, NC 28422 Chrys Baggett State Clearinghouse Budget and Management 116 West Jones-Street Raleigh, NC 27603 Dayne H. Brown, Director Division of Radiation Protection N. C. Department of Environment, Health & Natural Resources P. O. Box 27687 Raleigh, NC 27611-7687 H. A. Cole Special Deputy Attorney General State of North Carolina P. 0. Box'629 Raleigh, NC 27602

-Robert P. Gruber Executive Director Public Staff --NCUC P. O. Box 29520 Raleigh, NC 27626-0520 cc w/ encl: (cont'd on page 3) j' + a & - - - - w- e ae e-- -z w w , e. w-. ~ - s e m-, -

ww,-, - r>m. - . ,> - e,- - d-- - . - - , .

DEC111992 Carolina Power and Light Company 3 cc w/ encl: (cont'd)

Hs. Gayle B. Nichols l Staff Counsel SC Public Service Commission P. O. Box 11649 Columbia, SC 29211 bec w/encls:

Document Control Desk H. Christensen, RIl R. Lo, NRR NRC Resident Inspector U.S. Nuclear Regulatory Commission Star Route 1, Box 208 Southport, NC 28461

[

RII:DRSS RII:DRSS RII:DRSS RII:DRP I0 ETesta WRankin WCline HChristensen 2 ins

/ /92 / /92 / /92 / /92 (M(/92

• SEE NEXT PAGE FOR PREVIOUS CONCURRENCE

DE(J11 WJ2 Carolina Power and Li ht 9 Company 3 (cc w/encls: (cont'd)

Robert P. Gruber Executive Director Public Staff - NCUC P. O. Box 29520 Raleigh, NC 27626-0520 Ms. Gayle B. Nichols Staff Counsel SC Public Service Commission P. O. Box 11649 Columbia, SC 29211 bec w/encls:

Document Control Desk H. Christensen, RII R. Lo, NRR NRC Resident Inspector.

O.S. Nuclear Regulatory Commission Star Route 1, Box 208 Southport, NC 28461

/

RII:DRSS SS S1 3 Ril: RII:0E ET t WRankin line- (rifChristensen GJenkins p/il/92 l4/le/92 g/92 12/y/92 / /92_ -

i

- DEC111992 Enforcement Conference Brunswick .

December 7, 1992 Nuclear Regulatory Commission 3 C. Christensen,-Section Chief, Reactor Projects Branch, IA W. Cline, Chief, Radiological Protection and Emergency Preparedness Branch C. Evans, Regional Counsel D. Forbes, Radiation Specialist, Facility Radiation Protection Section J. Johnson, Deputy Division Director, Division of Reactor Projects R. Lo, Project Manager, Office of Nuclear Reactor Regulation /PD2-1 J. Luehman, Senior Enforcement Specialist, Enforcement and Investigation Coordination Staff M. Mizuno, Foreign Assignee from Japan R. Pedersen, Senior Health Physicist, Office Nuclear Reactor Regulation R. Prevatte, Senior Resident inspector, Brunswick W. Rankin, Chief, Facility Radiation Protection Section L. Reyes, Deputy Regional Administrator J. Stohr, Division Director, Division of Radiation Safety and Safeguards E. Testa, Senior Radiation Specialist, Facility Radiation Protection Section B. Uryc, Senior Enforcement Specialist, Enforcement and Investigation Coordination Staff Carolina Power and Licht Company R. Morgan, Interim Site Manager C. Priest, Jr., Refuel floor Project Specialist C. Robertson, Manager, Environmental and Radiation Control P. Snead, Manager, Radiation Control

- G. Warriner, Manager, Control and Administration D. Waters, Manager, Brunswick Licensing Unit R. Watson, Senior Vice President, Nuclear Generation J

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.-. ; .- n e L. s i , _ , , , - - , , , .,n , . ..n ---- - - - ,,--

J i\

CAROLINA POWER & LIGHT COMPANY--

BRUNSWICK NUCLEAR PROJECT ENFORCEMENT CONFERENCE t

December 7,1992

a

)

AGENDA introduction R. E. Morgan Overview G. H. Warriner Initial Conditions C. E. Robertson Sequence of Events C. E. Robertson immediate Corrective Actions C. E. Robertson

'J z-lety Gignificance C. E. Robertson

, Direct Cause/ Root Causes C. E. Robertson l

l Long-term Corrective Actions C. E. Robertson 1

o l Conclusions G. H. Warriner l

L Closing Comments R. A. Watson 2

l l --

OVERVIEW

-* Two apparent violations of 10CFR20

• Engaged in proactive evolution to address known '

problem '-

• Causes of event o Am/Be source not added to source inventory in 1978 o Less than effective assessment of risk

• Safety significance minimal _

• Response was comprehensive 3

(1lll la lliriti ii ii i i

.- s t .  :

' FUEL POOL CLEANUP PROJECT a

ORGANIZATION CHART I

SITE VP i

OM&M SECTION MANAGER j.

PROJECT MANAGER NUCLEAR' . . UNIT 1 .l_ RAD CON REFUEL MAINTENANCE O PE R ATION S.

ENGINEERING RAD CON SHIPPING FLOOR SUPERVISOR.' . SUPERVISOR :

S R .' E N G . SUPERVISOR ' ' SUPERVISOR - SUPERVISOR.

4 DEDICATED - 2 RC  : CONTRACT ~ 13 CREW LEADER RC TECHS. TECHNICIANS MECHANICS

, ' AND 7 CONT. .

4 --

4.

l

- ,. , ~.

4 lNITIAL CONDITIONS-September 22,1992

• Units 1 & 2 o Cold shutdown

• Unit 1 Fuel pool o Irradiated and non-irradiated hardware removed

• Unit 2 Fuel pool o Irradiated hardware removed o Demobilizing project

• Shipping o 52,708 Curies shipped without incident 5

l FUEL PObL WASTE ACTIVITY -

CURIES (Thousands) 60 ,.

. 50-4 40- -

t 4

30-4 20-

\

10-ssH.

0 5/1 2 6/12

.Date

SEQUENCE OF EVENTS

~ 9/14/92 Discovered startup source holder (SSH) on Fuel Pool floor Moved SSH to underwater work table to facilitate vacuuming 9/22/93 - Morning 0730 Crew leader decided to remove last items from underwater table (SSH & work pole) 1000- Upended SSH to verify no source present 1130 Performed underwater gamma survey of SSH Crew leader decided to dispose SSH as non-irradiated waste Power washed and sleeved SSH as removed from pool Second survey found ~ 2", 2 R/hr hot spot Crew leader decided to cut out hot spot 7

1 SEQUENCE OF EVENTS (Cont'd) 9/22/92 - Afternoon 1500- Prepared area for cutting work pole and SSH 1530 1540- Crew leader cut 2' center section from SSH 1600 around hot spot Placed 2' center section in high-rad waste drum Placed two outer 5' sections with other low-rad material 1600- HP's found contaminated smears higher than 1630 expected for this type of work during post-work surveys 1700- HP's and two plant decon workers began routine 1715 cleanup and experienced some difficulty with decon 1830 Personnel frisked clean at refuel floor and plant exit a

SEQUENCE OF EVENTS (Cont'd) 9/23/92 0700- HP's discussed level of contamination & decon 0800 difficulty One HP familiar with transuranic sources recommended precautionary check for alpha 0800- Resurveyed Refuel Floor and found alpha 0900 contamination 0900 RC Supervisor informed of alpha contamination Restricted access to Refueling Floor 1000- Extensive alpha surveys of plant started 1400 RC Project Specialist assigned to coordinate response Management informed Meetings with Project Manager, RC, & Nuclear Engineers to identify source of alpha contamination 1430- RC staff meeting to determine containment 1630 strategy, personnel surveys, bioassay, and car &

l home surveys, etc.

i

t IMMEDIATE CORRECTIVE ACTIONS

• Extensive surveys performed o Plant o Personnel automobiles, homes, and clothing o Effluents o Environment

• Comprehensive bioassays performed o Urine & fecal analyses o Whole-body counts at GE o Whole-body counts at Nuclear Fuel Services

-* Am/Be source surveyed for neutrons and secured

• Industry alpha expert retained 1

• Site incident investigation Team promptly convened

• - Recovery team estEblished to cleanup contaminated areas

• Plant's alpha survey capability. upgraded 10 g --

e

• Recognize this was a serious event

• Actual safety significance very low based on:

o Occupational exposure well within regulatory limits o No detectable exposure to public 3

o Am 241 contamination on-site is manageable k

11

SAFETY SIGNIFICANCE (Cont'd)-

• Occupational exposure well within regulatory limits l

I o 241 Am intake small fraction of 10CFR20 limit' Intake-

-:. Worker .

WCi)

MPC;ho'urs %of limit q

1. 1 6.4 53 10.2

1. -2 0.38 3 0.6

1. 3 0.41 3 0.6 Note: Limit is 520 MPC . hours / quarter 1-12

SAFETY SIGNIFICANCE (Cont'd)

• No detectable impact to public o Am 241 release did not exceed Technical Specification effluent release limits o Maximum calculated off-site dose < 0.01% of Technical Specification limit o No detectable Am 241 radioactivity off-site from environmental monitoring e Am 241 contamination on-site is manageable O Refueling Floor will be decontaminated by Dec 31 o Remaining activity confined to ventilation duct 13

DIRECT CAUSE Personnel were unaware SSH contained a source; Accordingly, personnel cut SSH using routine precautions appropriate for th' anticipated risk _.

14

ROOT CAUSE

• Source inventory did not capture Am/Be source o Source procured in 1978 and placed in Fuel Pool without adding it to any inventory

• Project planning did not provide work controls commensurate with risk o Formal guidance for handling materials of uncertain risk not provided o individual risk assessment should have been performed for each miscellaneous item o Too much reliance placed on knowledge of crew leader o~ Crew leader & HP's became the only barriers -

15

LONG-TERM CORRECTIVE ACTIONS

• Centralized responsibility for Fuel Pool management

• Added Am/Be source to source inventory

• Reviewed event with HP personnel emphasizing:

o Risks with neutron sources o Techniques for measuring alpha contamination

• Improved source inventory program by strengthening link between receiving and inventory control programs

• Upgrade Fuel Pool inventory program

• Review event with Outage Management and Technical Support personnel

• Revise Fuel Pool cleanup procedures for handling miscellaneous material to require risk assessment for miscellaneous materials

• Finalize disposition of Am/Be source

• Complete clean-up alpha contamination 16

CONCLUSIONS

• Engaged in proactive evolution to cleanup Fuel Pools o improve housekeeping o Establish baseline inventory o Reduce on-site radwaste hazards

• Causes of event o Am/Be source not added to source inventory o Less than effective assessment of risk

• Safety significance minimal o Occupational exposure well within regulatory limits o No detectable exposure to public 0 Remaining on-site Am 241 contamination is manageable

• Conducted prompt, thorough investigation e implementing effective corrective actions addressing root causes

• Response was aggressive and comprehensive i l

17 l l

4

l VENTILATION DUCT l.___

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j OFFICE ,

REFUEL BRIDGE d / T \  !

EQUIPMENT y

/> SPENT FUEL POOL HATCH

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$ CASK j WASHDOWN NN

.. l EQUIPMENT POOL

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NEUTKON SOURCE ICRITICAD CD.- D 19 ,

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TOP CU:Dt - HOLDER TIP .

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AME RICIUle-BERYLLtUM i

MEUTRON SOURCE CAPSULE

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RPV-Figure 2. Neutron Source Assembly VOL/>

F P 5 0 714PAGE (aO3 g _

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Am-Be Source .

(5.38 Ci - 1.04E7 n/Sec) .

~

Holder C-NNNNNN =>

3" source 14" Holder f

I ry

t AMERICIUM- 241 INTAKES AND INTERNALDOSE ESTIMATES WORKER INTAKE MPC-hours 50 Year 50 Year 1st Year CDE- bone CEDE - WB Effective (nCD (rem) (rem) (rem)

IIP' 1 4.4 36 36 2.0 0.066 6.4 53 52 2.8 0.096 3 3.1 0.2 - 0.006-IIP 2 0.38

, IIP 3 0.41 3 3.3 0.2 0.006

+

UNIT 2 REACTOR ROOF VENT AM-241 microCuries RE_ EASED .

i 180' i

160- '

140- '

g REPRESENTS LGSS THAN 0.01%

OF ANNUAL EFFLUENT LIMIT m 120- ' .

.92 100- ' '

,. B

O

$ 80- '

g 60- '

40- ' '

L 20- ' -

0' i.iiiiiiiiii i .

l 9/28 10/12 1.0/26 11/9 .11/23 WEEK ENDING

SOURCE COMPARISON

Sb/Be; .

T _AmmBe Irradiated Unirradated High gamma Low gamma Short halflife Long haNiife (No neutron) (Neutron)

Not transuranic Transuranic Commonly used Uncommon e-1 .

i o

r