ML20154R499

Corrected Notice of Violation from Insp on 880724-0802. Violation Noted:Licensee Promoted Individual W/O Completing Required Documentation & Individuals Improperly Performed Fit Tests When Donning Respiratory Protection Equipment

ML20154R499
Person / Time
Site:	Fort Saint Vrain
Issue date:	09/21/1988
From:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To:
Shared Package
ML20154R434	List: IR 05000267/1988017 ML20154R499
References
50-267-88-17, NUDOCS 8810040278
Download: ML20154R499 (7)

Text

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l . APPENDIX A NOTICE OF VIOLATION I

1 Public Service Company of Colorado Docket: 50-267/88-17 ,

Fort St. Vrain Operating License: DPR-34 l During an NRC inspection conducted during July 24 through August 2,1988,

violations of NRC requirements were identified. The violations involved

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(1) f ailure to follow procedures that affect quality, two exa.aples, and (2) a

' failure to implement the requirements of 10 CFR Part 20 requirements, two examples. In accordance with the "General Statement of Policy and Procedure

for NRC Enforcement Actions," 10 CFR Part 2, Appendix C (1988), the violations l are listed below A. Failure to Follow Administrative procedures i j .

4 I 10 CFR Part 50, Appendix B, Criterion V requires, in part, "Activities i affecting quality shall be crescribed by documented instructions,

procedures, . . . and shall be accomplished in accordance with these . . . l procedures . . . ."

Licensee Support Services Manager's Administrative Procedure-1 and Fort St. Vrain Administrative Procedure G-7, both require, in part, that i i specific documentation be completed and signed by senior plant managers prior to certain specified plant positions being filled. ,

i e

Contrary to the above, the NRC inspector determined on August 1, 1988,

, that the licensee, on or about June 25, 1988, had promoted an individual '

into the vacant position of Superintendent of Chemistry and Radiation .

without first completing the required documentation of SUSMAP-1 and G-7.  !

The licensee subsequently completed thy required documentation on J August 2, 1988, and implemented administrative controls to prevent a t j future recurrence of this violation. Due to the licensee's timely and  !

effective corrective actions concerning this matter, it will not be (

necessary to respond to this violation. l This is considered a Severity Level V violation. (Supplement I)  !

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(267/8817-01)

, B. Failure To Follow Procedures l Licensee Health Physics Procedure HPP-16 requires, in part, that prior to 4 use full face air purifying respirators be negatively pressure fit tested

) by the wearer to ensure air tightness at respirator sealing points.

Contrary to the above, the NRC inspector observed on July 26, 1988, two individuals improperly perform fit tests when donning full-face air

purifying respiratory protection equipment prior to entering an airborne j radioactivity area.  ;

i 000 o??k 0$0@Q aof,qa gp l 1

2 This is considered a Severity Level IV violation. (Supplement IV)

(267/8817-04)

C. Respiratory Protection 20.163 10 CFR Part 20.103(c) requires, in part, "When respiratory protec * .i equipment is used to limit the inhalation of airborne radioactive naterial . . . . The licensee may make allowance for this use of respiratory protective equipment in estimating exposures of individuals to this material provide that: .... The licensee maintains and implements a respiratory protection program that includes, fitting, . . . and testing of respiratory for operability immediately prior to each use; written procedures regarding supervision and training of personnel."

Licensee HPP 16 defines the licensee's available respiratory protection equipment, selection criteria, preuse test.ing, available protection factors, and equipment limitations. Also, licensee training lesson plan GE 018.03 defines the licensee presentation for respiratory protection training.

Contrary to the above, the NRC inspector determined on July 28, 1988, during the presentation of respiratory protection training that instructions on both radiological and industrial applications of respiratory protection equipment were inadequate regarding fitting and testing for operability immediately prior to each use, and that Hpp-10 did not implement adequate use instructions on all available respiratory protection equipment.

This is considered a Severity Level IV violation. (Supplement IV)

(267/8817-02)

D. Radiation Area Post.ing 20.203 10 CFR Part 20.203 requires, in part, "Each radiation area shall be conspicuously posted with a sign or signs bearing the radiation caution symbol ard the words: Caution Radiation Area."  ;

l 10 CFR Part 202(b)(2) defines "Radiation Area," in part, ". . . as any area accessible to personnel, in which there exists radiation . . . at such levels that a major portion of the body could receive in any one 5our a dose in excess of 5 millirem, or in any 5 consecutive days a dose in excess of 100 millirem;" This requirement is for protection of personnel entering a 10 CFR Part 20.5 "Restricted Area," and is considered to encompass a normal 40-hour, 5-day work week.

Contrary to the above, the NRC inspector determined on July 26, 1988, that the licensee's procedure for posting of radiation areas required l

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posting only if general area radiation levels exceeded 2.5 millirem per l i hour, and that some licensee personnel were working a mandatory 6-day work '

week, with 91/2-hour work days. The combination of radiation levels and .

j the 47.5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br /> in a 5-day period would cause an individual to exceed the l

100 millirem limitation. l 4

! This is considered a Severity Level IV violation. (Supplement IV) i (267/8817-03) i

Pursuant to the provisions of 10 CFR 2.201, Public Service Company of Colorado 4

is hereby required to submit to this office, within 30 days of the date of i letter transmitting this Notice, a written statement or explanation in reply.

• including for each violation: (1) the reason for the violations if admitted, j (2) the corrective steps which have been taken and the results achieved, "

I (3) the corrective steps which will be taken to avoid further violations, and ,

l (4) the date when full compliance will be achieved. Where good cause is shown, ,

i consideratien will be given to extending the response time.  !

I Dated at Arlington, Texas i this 21st day of September 1988. j l

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APPENDIX B U.S. NUCLEAR REGULATORY COMMISSION REGION IV NRC Inspection Report: 50-267/88-17 Operating License: OPR-34 ,

Docket: 50-267  :

Licensee: Public Service Company of Colorado (PSC) 2420 W. 26th Avenue, Suite 15e i Denver, Colorado 80211 <

Facility Name: Fort St. Vrain Nuclear Generating Station (FSV)  !

Inspection At: FSV Site, Weld County, Platteville, Coloraco  !

Inspection Conducted: July 24 through August 2,1983 i

i Inspector:[HD:

W Chaney, Radiation Specialist, Facilities Fate 8'/M --

l Rtdiological Prote.. tion Section '

l Approved: [_ ___ ] W ,

/4/c' l Lte R. 4. Baer, Chief, Facilities Radiological  !

Protection Section l Inspection Summary  !

Inspection Conducted July 24 through August 2,_1988 (Repor;t_5;;r267/fg _

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Areas _Intpected: Ratine, unannounced inspection c,f the licenssa's radiation  !

protection program. l Results: Within the areas inspected, four violation itw vic htloN for f ailure to implement 10 CFR Part 20, see paragraphs 5 and (; and two vio'atiera l for failure to follew procedures, ss ee pecapraphs 4 snd 7) wtre identif ts.t No  !

deviations were identified l

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1 CGTAILS i

1. Parsons Contacted i 4

P_SC i *R. O. Wi!)ien, J. ., Vice President, Nuclear Operations

• F. J. Beest, Hv:letr Training Manager -

*D. W. Evan% 00avations Manager t

• D. Gep, Regulatory Af fairs Manager

• J. M. Gnuniing, Supervisor of Nuclear Licensing  ;

• J. t Hak, Mr.intenance Supervisce '

*M. 'i. H01mu , Nuclear Li ensic.g Manager I i

• R. O hoonr, Nuclear Training Administrative Supervisor '

Q. D MiMar, Radiochemistry Supervisor

">. F. Kiare, Quality Assurance (QA) Supervisor ,

! 'F. J. Novachek, Nuclear Suppor Manager

'l D. Scott, QA Services Manager

[ *S. i. SMrrow, Health Physicist 1 *L. R Sutter., QA Auditing Supervisor  !

] Ps f, fomlinson. QA Manager i W. Voodard, Acting Radiation Protection Supervisor

'6 2 err, QA Engineer 4

0hers

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! R. E. Ferrell, NRC Senior Resident Inspector  ;

] *P. W. Michu:d, NRC Resident Inspector c

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• Denotes those individuals present during the exit interview on August 2, i j 1988.  !

l The NRC inspector also interviewed several other Itcensee employees 3

! including quality control inspectors, maintenance mechanics, radiation '

protection personnel, clerks, and training instructors.  :

! 2. Followup on Previous _l,nspection Findings i

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2 (Closed) Violation (267/8707-01): Radioactive Liquid Effluent Releases - i l This item was previously discussed in NRC Inspection Reports 50-267/87-07  !

and 87-24 and involved the licensee's failure to perform the required I radiological sampling prior to a liquid effluent release. The NRC  !

, inspector reviewed implementation of the licensee's corrective actions

• 1 stated in the response to the Notice of Violation, dated May 7, 1987, the

corrective actions referenced in Licensee Event Report 87-004~, and the r licensee's corrective actions taken by the licensee in response to an  !

4 associated QA Department audit finding (CAR 87-023). The licensee's  :

corrective actions appear to be adequate to prevsnt a reoccurrence of the violation in the future. ,

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l l (0 pen) Violation (267/8420-02): "Effluent Monitoring Instrumntation -

This item concerned the licensee's commitment to install a continuous reactor building sump liquid release pathway monitor that would provide 4 monitoring for radionuclides that predominantly decay by beta radistion.

The licensee committed to providing quarterly progress reports on the development of the monitoring system. The licensee's most recent progress report (Final, October 22, 1987) indicates that the development of beta

' monitor (beta scintillation cell) had encountered severe difficulties due ,

to the foreign material contamination within the sump and its detrimental affect on the monitor's scintillation crystals (calcium fluoride). The  :

i licensee has abandoned further effort in developing a sump monitoring  !

system and has petitioned the NRC for relief from their commitment to develop such a system. The licensee has requested permission to continue to utilize the batch release manual sampling of sump liquified effluents as has been used since the violation had occurred in 1984. This item will .

remain open pending NRC action on the licensce's petition and verification  !

of licensee implementation of any corrective actions so directed. i i

(0 pen) Open Item (267/8221-04): High Range Noble Gas Effluent Monitors, i NUREG-0737 Item II.F.1.1 - This item was most recently updated in NRC

Inspection Report 50-2T/787-24 The NRC informed FSV via letter and 1 Safety Evaluation Report, dated January 9, 1986, that the licensee's proposed design and design improvements to the installed postaccident reactor effluent activity monitor to be acceptable. The licensee had

. committed to installing a dilution system (sometime in 1988) to extend the

) measurement range of the monitor (RT7324-2). The licensee had revised the

, commitment on installation of the dilution system and it will be installed l (design change notice: CN2042) prior to the resumption of reactor power L operations following the fourth refueling outage (some time during 1989). '

This item is considered open pending completion of licensee actions and verification of operability of the dilution system.

! 3. Open Items Identified During This Inspection An open item is a matter that requires further review and evaluation by '

the NRC inspector. Open items are used to document, track, and ensure i adequate followup on matters of concern to the NRC inspector. The  :

following open items were identified: I

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Open Item Title See Parcaraph !

267/8817-05 Hot Particle Exposure Assessment 6 l Methodology j 267/8817-06 Industrial Respiratory Protection 5  !

j Program l i

j 267/8817-07 Hot Particle Control Program 8 '

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267/8817-08 Fixed Contamination Units of 8 Measurement 267/8817-09 Release of Materials for Unrestricted 8 Use 267/8817-10 Contaminated Material Ree,eptacle 8 locations i

4. Organization and Management Controls - Radiation protec, 2n _

{83522/83722)

The licensee's organization and staffing of the radiation protection group l was inspected to determine agreement with commitments in the Updated Final .

Safety Analysis Report (UFSAR) Sections 11 and 12; and compliance with the ,

requirements of Operating License Technical Specifications (TS) 7.1, 7.3, l 7.4, and 7.5; and the recommendations of NUREG-0731 and 0761. (

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The NRC inspector reviewed the licensee's organization, staffing, assignment of responsibilities, radiological protection program j implementing procedures, Radiation Protection Plan, completed and

j scheduled QA audits, and management oversight of radiological work j activities. Senior Management Policies in regard to radiation protection, respiratory protection, and ALARA were also reviewed.

The licensee had recently selected a new Radiation Protection Manager (RPM). The RPM position was previously held by the Support Services Manager. The new RPM position is titled Superintendent of Chemistry and ,

Radiation Protection (SCRP). The previous RPM was assigned full time '

duties as manager of the onsite Nuclear Training Department. The new SCRP position was created during a major personnel reorganization of FSV in r May 1988. This position (RPM /SCRP) no longer has direct access to the Nuclear Productlen Division Manager (NPM) (equivalent to the position of r Plant Manager) but reports through the realigned position of Manager of Nuclear Support Department. The NRC inspector determined that even though l

current TS and UFSAR charts do not provide clear lines of tuthority to the I

] NPM for the RPM, there is a clear understanding that the RPM can contact 4 the NPM at any time to resolve radiological protection problems not resolved through the normal chain of command.

j The NRC inspector determined that a new SCRP position was permanently

) filled on or about May 26, 1988, by the incumbent Health Physics (HP)

' Supervisor.  ;

i l 10 CFR Part 50 Appendix B, Criterion V, requires that activities i affecting quality shall be prescribed by documented instructions, l j procedures, or drawings of a type appropriate to the circumstances and

shall be accomplished in accordance with these instructions, procedares, or drawings. Instructions, prncedures, or drawings shall include

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appropriate quantitative or qualititive acceptance criteria for i i

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I determining that important activities have been satisfactorily accomplished. ,

i FSV Support $ervices Manager's Administrative Procedure (SU5 MAP) 1, ,

"Health Physics, Radiochamistry and Chemistry Experience, Qualification, l and Training Requirements," (Revision 14, dated July 29,1987), r paragraph 3.1.2 states, in part, "The RPM shall meet the requirements of ,

Regulatory Guide 1.8 - 1975 . . . prior to assignment to the position.

l This shall be documented on Attachment SUSMAP-1M." SUSMAP-1M requires the signature of the NPM. Also, FSV Administrative Procedure G-7.."FSV i Project Personrel Training and Qualification Programs," (Revision 20, dated June 22,1988), paragraph 4.1.3, requires that qualifications of individuals filling certain positions at FSV be evaluated to specific J industry prescribed criteria and documented on Attachments G-7A and G-78 ,

to the procedure. Paragraph 4.2.4 of Procedure G-7 identifies the TSV equivalent position of RPM as requiring verification of the assignees qualifications at the time of appointment to the active position.

I The NRC inspector determined that as of August 1, 1988, that the documentatier, rec.uired by S'JSMAP-1 and G-7 had not been initiated for the individual assigned to the position of RPM /SCRP, This failure to comply with procedural requirements is an apparent violation of the requirements of 10 CFR Part 50, Appendix B, Criterion V. (267/8817-01) j 4

The liceasu indicated that failure to initiate the proper documentation i was a result of two separate occurrences: (1) the reliance on a comprehenstvN review of the selectee's qualifications that was performed in late MB7, as documented by a memorandum to file by the former RPM, and (2) the new d4partment manager of Nuclear Support had not made himself

fully familin with the department's implementing procedures (%USMAP), and ,

there was 4o m hanism in place to ensure that managers performed the '

i SUSMAP-1 or G-? evaluations. This resulted in the requirements being

] overlookec. The licensee took immediate action to complete the required l

documentation, the manager familiarized himself with the SUSMAP i j procedures, u d changes were initiated to personnel administrative action

checklists to ensure that the requirements of SUSMAP-1 and G-7 (G-7 is the primary govermna procedure) will be complied with, as a routine matter, l j

i during any future personnel selections involving G-7 identified positions. l j Due to the lict.nsoe's timely correction of the apparent violation, j identification of the root cause, and implementation of effective i corrective action to prevent a recurrence, no response to this apparent j

violation (267/M17-01) will be necessary.

I The licensee has experienced a turnover rate of approximately 60 percent l within the radiat'On protection group in the last 12 months. The lossas

involvd health physics technicians (HPTs) and mostly involved transfers

(5) to other operational groups at FSV. Currently the licensee's radiation protection staff consists of 1 SCRP, 2 health physicists,

! 12 HPTS, and 1 vacant Health Physics Supervisor position.

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Licensee procedures and documents reviewed are listed in the attachment to this inspection report.

No deviations were identified, j

5. Training and Qualification - Radiation Protection (83523/83723)

The licensee's radiologic 61 training and the radiation protection  ;

personnel qualification program were inspected to determine agreement with ,

commitments in Section 12 of the UFSAR; and compliance with the j requ'.rements of TS 7.1.2.g, 7.1.2.h, 7.1.2.1, 7.1.3, and 7.3.b.7, 10 CFR .

Part 19.12; the recommendations of NRC Regulatory Guides (RGs) 8.13, 8.27, f 8.29; Irdustry Standard ANSI 18.1-1971; and HUREG-0041 and 0761.

Tne NRC inspector reviewed the licensec's radiological training programs for permanent piant employees, visitors, and contractors. Lesson plans I and student reference material were reviewed for content. ,

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Instructor qualifications and training were reviewed. The NRC inspector observed selected general employee training (GET) and radiological worker training classes. The licensee had received INP0 accreditation of all their training prcgrams in May 1988.

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The licensee's HPT training program, including on-the-job-training, was ['

reviewed. Individual experie. ice and qualification for all personnel in J the radiation protection group were reviewed. l The NRC inspector attended the licensee's radiation worker and respiratory 4

protection training recua11fication programs on July 28, 1988. Tne licensee's requalification program for respiratory protection training is 1

the same as the initial qualification training provided radiological ,

workers. The licensee's GET is structured as Category 1 Training - '

Personnel not entering radiological work areas or radiation areas, - i Category !! Training - Personnel entering the reactor building but not l engaging in radiological controlled work activities, and Category I!!

/ Training - Personnel engaging in radioltgical work activities at FSV, and ,

also includes respiratory protection training, i

I 10 CFR Part 20.103 establishes requirements for implementation 1 1 ef an acceptable respiratory protection program that may take advantage of

- the protection factors assigned to various respiratory protection i equipment (RpE). Qualitative guidance on suitable equipment, procedures, j user training, instructor qualifications, and content of written

, instructions are contained in NRC RG 8.15 and NUREG-0041. 10 CFR 4

Part 20.103 requires that written procedures for selection, use, supervistor, and training involving respiratory protection equipment be implemented.

FSV Lesson Plan GE 018.03, "Internal Exposure Control, Respiratory Protection Program." sets forth the training necessary to qualify a j worker to use RPE.

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. i FSV HPP 16, "Selection and Use of Respiratory Protection Equipment," "

provides written instructions on the selection and use of several

different types of RPE.  !

The NRC inspector determined during the observation of Category III training and a review of the licensee's implereenting procedures that the  ;

licensee's RPE program lacked the following:  :

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o Training on the proper ways to verify a suitable face-to-respirator

I' r.atk seal for respirators other than self-containsd breathing l apparatus (SCBA) models. Personnel were not required tu demonstrate l l proficiency on full-face airline or air purify models which are i commonly used and available, j Sufficient Instructions were not provided personnel on the types of

] o j cartridges and canisters available for both radiological and i nonradiological uses, and their 1tmitations. The licensee has i approximately five different chemical and particulate filter  :

canisters available onsite,

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i o The instructor lacked familiarity with certain equipment (chemical ,

j cartridges, airline respirator hose length limitations and pressure requirements), and locations of emergency equipment. ,

1 o The instructor's experience level with kPE was very limited and he  !

had not received any professional training ir acceptable industrial j j or radiological applicatio?s of RPE.

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] o The instructions concerning preuse tetting of the SCBAs was deficient  ;

i in that personnel were net instrected on the necessity of verifying

that the low pressure alarm was operational. This is reevired by the  ;

SCBA's manufacturer in their ase arid operating instructions. i I

I, o The training program did rot address limitations or prat.ction  !

l factors for use of RPS in airborne concentrations of tritium and l i noble gases.

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o The training did not discuss sufficiently nonradiological hazards i existing at FSV (chlorine, helium, ammocia, or asbestos) and the i 1 a v ailable: protective aquipment (canisters / cartridges).  !

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The NRC ingr*, tor determined that the license &'s program for respiratory l i protection training and management of the RPE program requires furth6r

j evaluation aid is enn:1dered and open item. (267/8817-06)

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{ The NRC lospector noted that a QA audit (HPHY-87-01) of respiratory l j prottction practicos revealed deficiencies in the licensee's ability to t i ensure persoonel medical reviews and RPE training are conducted within the

time ptriod referenced in procedures. These deficiencies were corrected.

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8 The NRC inspector noted that the licensee instructs personnel oil applic.ble RPE protection fseters and makes use of the applicable protection factors when evaluating uptakes of airborne radioactive materials by personnel. Due to the many deficiencies in the licensee's written procedures and trairiing program for RPE use, the NRC inspector requested thst the licer;see no longer take credit for rrotection factors as allowed by 10 CPR Part 20.103(c). The failure to implement an acceptable respiratory protection program is considered an apparent ,

violation of 10 CFR Part 20.103(c). (267/8817-002) .

No deviations were identified.

6. External Exposure Control an_d personal Dosimetry (83524/83724)

The licensee's external radiation expo 3ure control program was reviewed for: agreement with the commitments in Section 11 of the UFSAR; compliance with the requirements contained in TS 7.4.d; 10 CFR Parts 19.12, 13, and 20.101, 102, 104, 105, 202, 203, 205, 206, 405, 407, 408, a d 409; and che recommenJations of NRC Inspection and Enforcement Information Notices

(!EIN) B b23 and 87-39; RGs 8.8, 8.13, 8.14, and 8.28; and industry standards ANSI N13.11-1983.

The NRC inspector reviewed personnel exposure records, records storage facilities, exposure control procedures, dosimetry processing procedres, dosimet ry quality control methods, data prMessing, and report generation.

Facilisy inspections were made and indepenc'ent measurannts were conducted of posted radiation areas. The licenste's high radiation area controls, incluaing locking and control of keys, was inspected. Accreditation of the licensee's dosimetry processor was verified. The licensee's on hand t

stock of extremity dosimeters and spara film badges for personnel monitoring was reviewed. The NRC inspector observed the use of multiple '

dosimetry for personnel entering areas with non-uniform radiation fitids. ,

TS 7.4-3.d requires, in part, "Procedure > for personnel radiation protection shall be prepared consistent with the requirements of 10 CFR Part 20, and shall be approved, maintained, and adhered to for :11

, oporations involving pertornel radiation exposure."

10 CFR Part 20.203 requires, in part, "Each radiation arve shall be cunspiccously posted with a sign or signs hearino the radiation caution

! symbol and the words: CautionRadit?snArea."10CFRPart202(b)(2)

! defines "Radiation Area," in part, ". . as any area accessible to

personnel, in which there exists radiatien . . . at such levels that a 1 major portiot, of the body could receive in any one hour a dose in excess l of 5 31111 rem (mren), or in any 5 consecutive days a dose in excess of 4 100 mrem;" This requirement is for protection of perennel entering a i 10 CFR Part 20.5, "Restrit.ted Area," and is considered to encompass a i nereal 40 c.aur, 5-day work week.

The hDC inspector determined on July 26, 1988, that the licensee's ,

precedure for posting of radiation areas (HPP-9, "Establuhing and Posting Controlled Areas") required, in paragre';h 6.1.1, that "Establish an area

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0 such that radiation dose levels at the boundary do not exceed '

2.5 rrrem/heur (br). This value was discussed with the licensee and was found to bis based on a person not exceeding 100 mrem in 5 consecutive days *

! (8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> a day for 5 days: 40-hour work week). This would result in a person receiving equal to, or less than 100 mrcm of exposure when working  !

near the boundary. This requirement had been in effect for several years.

i Licensee internal correspondence for the Daily Helium Circulator Outage  ;

2 Meetings established, as early as June 29, 1988, that shift work hours for work crews would be 91/2-hour shifts, 6 days a week. This work schedule  !

would result in a person working near the same barrier to receive an exposurti in excess of 100 mrem. A review of selected posted radiation

! areas did not reveal any boundaries exhibiting dose rates greater than 2.0 mrf m/hr. The failure to properly implement the requirements of 10 CFR Part 20.202 is considered $n apparent violation of TS 7.4.d. (267/8817-03)

The NRC inspector reviewed the licensee's program for hot particle control and sAin exposure evaluation. The licensee's procedure (HPP-11) for

calculating skin dose due to radioactive contamination or hot particles on ,

i the skin of the whole body does not utilize tha VARSKIN dose calculation '

i methodolcgy recognized by the NRC. The licensee's skin dose calculation  ;

procedure appears to produce overly conservative exposure values and  :

uses units of measurement (counts per minute - CPM) that can not be ,

1 readily converted to dose. The licensee's procedure does not address the '

, use of portable ion chamber type dose rate measurement instruments for assessing radioactivity levels on the skin. The licensee was provided

] information on the VARSKIN program and NUREG/CR-4418. The licensee stated '

a that the VARSKIN methodology would be reviewed for possible implemen-  !

tation. The licensee has identified relatively low level (10,000 l disintegrations per minute - OPM) particles of radioactivity during ,

routine contamination surveys, but has not had any significant incidents ,

invoiving skin contamination. Licensee contamination control practices I j are discussed in paragraph 8 of this report. ,

< l j The NRC inspector considers the licensee's implementation of a hot j particle exposure evaluation progran to be an open item pending licensee '

j completion of an evaluation of their skin dose assessment methodology to

that recognized by the NRC. (267/8817-05)

No deviations were identified.

7. Internal Radiation Exposure Control.,and Assessment (83525/83725) l l The licensee's internal radiation exposure control program was reviewed 1 for agreement with the comitments in Section 11 of the UFSAR; and

) compliance with the requirenents contained in TS 7.4.d 10 CFR Parts 19.13 i and 20.103, 108, 203, 206, 401, and 405; and the recommendations in NRC J

RGs 8.8, 8.13, 8.15, 8.20, 8.26, and 8.28, NUREG-0041, .ind industry standards ANS! 13.1-1969, and N343-1978.

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l l The NRC inspector reviewed the 11cera.ee's implementing procedures;

, management policies governing use of GPE; programs and activities

! involving routine and emergency aspects of the internal dosimetry, air l sampling, and analysis; ant. vosting of airborne radioactivity areas. The l licensee's program for moniuring and evaluation of t 'itium uptakes was l reviewed to determine compliance with the limits established in 10 CFR ,

l Part 20, Appendix B, and industry accepted calculational methodologies. l l Tritium uptakes appear to be negligible at lens than 1 percent of a  ;

maximum permissible organ (whole body) burden. The NRC inspector observed (

on going work activities involving high levels of loose radioactive contamination *he usa of containment enclosures, engineered ventilation systems, breathing zone dir sampling, and use of RPE.

TS 7.4.d requires, in part, "Procedures for personnel radiation protection shall be prepared consistent with the requirements of 10 CFo Part 20, and l shall be approved, maintained, and adhered to for all operation $ thyolving l personnel radiation exposure. Respiratory protective equipment shall be provided in accordar,ce with 10 CFR Part 20.103." HrP-16. "Sele: tion and Use of Respiratcry Protection Equipment," paragraph 5.2.2.6. requires that a "Check for the proper fit by placing hand over the air inlet tcles in the filter and inhale gently. A gas tight fit .4111 be indicated . . . ."

The NRC inspector observed on July 27, 1988, twe FSV employees, in '

preparation for entering a posted airborne radioactivity area, remove the high efficiency filter from their full face respirators and perform a se,1 l test by blocking off, with their h..nd, the respirator coupling nut for the removed filter. Upon completing this test, the employees reattached the r filter without verifying that the filter was properly sealed to the respirator. The NRC inspector brought the apparent improper testing to the attention of the senior HPT covering the job and the employees were required to retest the respirators in accordance with the requirements of L i HPP-16. This was accomplished successfully prior to the employees  ;

entering the airborne radioactivity area. Licensee representatives f indicated that testing of the respirator without the filter on was the way l they were trained. The NRC inspector could not verify this during l discussions with training department instructors or review of training material. The acting HP supervisor immediately issued a notice that informed all HP personnel on the proper way to preuse check a full face  ;

respirator for proper fit. The failure to properly test RPE prior to use l 1s considered an apparent violation of TS 7.4.d. (267/88G-04) .

No deviations were identified.

8. Control of Radioactive Materials (RAM) and Contamination. Surveys, and Monitoring (83526/81726)  ;

I The licensee's programs for the control of RAM and contamination. l radiological surveys and monitoring were reviewed for agreement with the t commitments 'n Section 11 of the UCSAR; compliance with the requirements  !

of TS 7.4, 10 CFR Parts 19.12, 20.4, 20.5, 20.201, 20.203, 20.205, 20,207, }

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11 20.301, 20.401, 20.402, and NUREG-0737, Item III.D.3.3; and the recommendations of IEIN 85-06, 85-92, 86-23, 87-39, IE Bulletin 80-10, and IE Circular 81-07.

The NRC inspector toured facilities; conducted independent gamma rcdiition dose rate measurements and loose surface contamination surveys; reviewed ongoing work operations within tiit reactor building and turbine building; reviewed Radiation Work Percits, radiation, airborne and surface contamination surveys (routine and work related); and observed analysis of radiological samples and the use of laboratory counters, response checking of instruments, and the updating of plant radiological information maps.

The licensee's analytical equipment provides for bets and alpha radioactivity analysis, and the c.oluation of air samples for iodine and other fission products.

The NRC inspector reviewed the licensee's program for protection against and control of hot particle areas (as referenced in IEIN 86-23 and 87-39).

, Even though the licensee has two areas (hot service facility and the refueling deck) that could be the source of hot particles (activation particles and fuel fragments), the licensee had not trained employees, i developed a hot particle control pregram, or implemented a special survey program for determining the denree of hot particle contamination. The licensee does not currently utilize high sensitivity automatic whole body contamination monitors for surveying personnel exiting loose surface contamination control areas. Whole body frisking with a hand held beta / gamma sensitive pancake probe is currently utilized. Standard portal monitors for detecting moderate radioactive contamination levels (0.5-2 microcuries of cesium-137 equivalent radioactivity) are used by site personnel prior to each exit of the protected area. The licensee's lack of a documented hot particle program and lack of employee training on the nuclear power industry het particle problems is considered an open item pending action by the licensee. (267/8817-07)

Due to an INPO commitment, the licensee has adopted in MPP-21, the use of referencing fixed radioactive contamination survey results below the level of 0.5 mrem /hr in the units of CPM which is not directly relatable to 10 CFR Part 20.5 required units of mrem DPM, or curies. The licensee '

stated that survey forms for documenting the fixed radioactivity results contain sufficient information to allow conversion of the CPM data to 10 CFR Part 20.5 units. The NRC inspector determined that while the necessary information was traceable, there could be confusion as to which '

instrument data on the results forms was applicable to fixed radioactivity measurements. This is considered an open item pending action by the licensee. (267/8817-08)

The licensee procedures for release of radioactive material (not wastes) complies with the guidance given by the NRC in IE Circular 81-07 and is also in agreement with tha guidance given to the licensee by the state of Colorado. Currently, materials (tools and ecuipment) with a post decontamination fixed radioactivity levels of less than 0.4 mrem, as i

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, measured with a beta / gamma sent!tive detector, can be released for unrestricted use and possible disporal. This licensee uses a conservative l

limit, based on laboratory counting equipment limitations, for the levels l of loose surface contamination allowed on material to be re' eased for l unrestricted use. The NRC inspector noted to the licensee that current l NRC interpretative guidance (IEIN 85-92, and NRC Staff Letter G. W. Kerr l [NRC] to E. D. Bailey (Texas Bureau of Radiation Control]; Su'oject:

I Clarification of the Regulatory Control Over Independent Service Company '

Waste and Equipment Processing Used at Licensed Facilities, dated May 6, 1986), established that the appropriate release limit to be applied by licensee's for evaluating the release of potentially radioactive material ,

from licensed facilities is "No detectable radioactivity." Licensee representatives indicated that they would reevaluate their material release program with regard to the above noted guidance. This is ,

I considered an open item pending action by the licensee. (267/8817-09)  :

The NRC inspector noted during tours of the licensee's facilities and comparisons with training films used in Category III (radiological worker training) that receptacles used for disposal of radioactively contaminated clothing and wastes at work sites are 1(,cated, contrary to industry practices and licensee training presentations, on the outside of contamination control boundaries (clean side). This is not a good practice for controlling contamination or hot particles. The licensee issued written instructions on August 2, 1988, to all HPTs on placing disposal receptacles on the inside of controlled areas. This is '

considered an o en item pending further NRC icspector review during future i inspections. 2 T8Tf7-10) ,

No violations or deviations were identified. l t

9. Radiological Control Facilities and Equipmer'./ Instruments The licensee's facilities for radiological protection activities during routine and emergency situations were reviewed for agreements: with  !

commitments contained in Sections 12.3.2 and 12.3.4.E of the UFSAR; i Section 7 of the Radiological Emergency Resronse Plan (RERP) - Station;  !

and the recommendations of RG 1.97, 8.8, 8.25; NUREG-0041 and j NUREG-0654/ FEMA-REP-1. <

The NRC inspector inspected training facilities, respirator decontamination and maintenance facilities, HP counting laboratory, I postaccident sampling system, calibration, and hot-work facilities, l robotic equipment for handling highly radioactive materials, radioactive source storage, locker and toilet facilities for workers, radiological i controlled area access control point, first aid facilities, machine shop for radioactive materials, decontamination facilities for personnel and.

equips tnt, and emergency equipment inventories (RP response survey equipnient, respiratory protection equipment, and protective clothing) at the onsite technical support center. Selected equipment referenced in Table 7.3-1 of the RERP - Station was verified to be present and i

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13 operational. Operation of the portal monitors at the exit to the protected area was verified. Instructions were posted as to actions to be taken if the portal monitors were to alarm.

No violations or deviations were identified.

l 10. ALARA Program 1

The licensee's ALARA program was reviewed to determine agreement with the commitments in Section 11.2 of the UFSAR; the requirements of 10 CFR Part 20.1(c); and the recommendations of RGs 8.8, 8.10, and 8.27.

The NRC inspector reviewed the licensee's new (August 4, 1987) ALARA plan.

The implementation of this ALARA plan resolves an NRC concern discussed in the licensee's 1986-87 Systematic Assessment of Licensee Performance Report (50-267/87-06). The licensee's ALARA plan has all the attributes of a good exposure reduction program. Workers knowledge and work practices demonstrated a good working knowledge of ALARA practices. The NRr inspector reviewed ALARA committee meeting minutes. The Plant Health Physicist is designated as the station ALARA coordinator.

FSV's exposure expenditure for 1987 was 1.24 person-rem as compared to a national average for all light water reactors of 420 person-rem. FSV was not operating for approximately 10 months of 1987.

11. Advance Planning and Preparations The NRC inspector reviewed the licensee's preparations for a 92-day nonrefueling outage, which began on July 5,1988. The NRC inspector revieweti the scheduling and preplanning for removal, inspection, and repair of the reactor coolant circulators. The NRC inspector observed the removal and inspection of helium circulator "B." Previous experience data provided to the Lead HP technician indicated that loose radioactivity could exceed 1 million DPM per 100 square centimeters with gamma radiation levels of 30 mrem /hr general area and 100 mrem /hr on contact with components. Contact beta radiation levels of 10 rad /hr were expected.

The preparation and inspection of the spare helium circulator which was placed in the "B" cavity was also observed. The NRC inspector discussed with outage coordinator. the observation that even though the circulator procedure, Maintenance Procedure (MP) 2225, contained extensive HP work and survey sign-offs, and the HP department provided a supplementary procedure to MP 2225, there were little if any specific instructions on contamination containment requirements for separation of the circulator from its removal shield, ventilation requirements, or respiratory protec-tion needs. This job had been accomplished six or more times in the past.

The maintenance personnel indicated that several containment methods have been used in the past. The NRC inspector noted that the HPTs stopped work often and held briefings on work activities and required radiological controls during the course of circulator "B" work. The HPT covering the job were fully qualified HPT with several years of light water reactor

. . . . . . .. -_ ,. .-- - - . _ = - -.

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i experience but had little if any experience with work on helium  ;

circulaturs. The licensee stated that supervising HP and maintenance  :

personnel were developing supplemental procedures that would permanently clarify all aspects a helium circulator removal, inspection, shipment, and  !

) replacement, c No violations or deviations were identified.  ;

I l l 12. Exit Interview  !

.; The NRC inspector met with the NRC resident inspector and licensee i j representatives denoted in paragraph 1 on August 2, 1988, and summarized l 4 the scope and findings of the inspection as presented in this report. The  ;

- licensee committed to reviewing their respiratory protection program for

! agreement with RG 8.15 and NUREG-0041.  !

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j ATIACHMENI' I i ,

1 DOCUMENIS REVIEWED FOR f NRC INSPECTION REPORT  !

50-267/88-17 l

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I I I ll; E ISSUE NUMBER DATE {

, I l Pub l.a c _59r y t co _ Company _gL.Colprado _ppetat i nus_Eol tc z es'  !

4 I

d Radiation Protection Guideline No. 7-3. Respirstorv [

Protect ion Policv O2-07-84 (

FSV_Admi ni sttet t ve PCOGeduCMP t i G-5. Personnel Emeroencv Response 22 05-24-88  !

4 G-7 FSV Project Personnel Traininq  !

Oualification Programn 20 06-22-88 ,

G-19 Performance Indicator Procram 01 07-14-87  !

j G-20. As Low As Is Reasonably i

Achievable (ALARA) 01 '08-04-87 [

1 ,

P-3. Radioactive / Contaminated Waste / Area l 1' Control 13 12-03-87  ;

P-10, Industrial Safety Prooram 06 05-20-86 i ,

I r

{ 0-1. FSV Oroanization & Responsib111 ties 09 09-23-86 j I

h SUDR9Ct_6*CYicen_d80aggtg_Odminigttettyg_Etggedytes_JSUSUSE)- f e

SUSMAP-1. Health Physics. Radiochemistry, i

f end Chemistrv Experience. Qual j ification and Trainino Require l i ments 14 07-29-87 t

! SUSMAP-2 Offsite Dohe Calculation Manual i and Radiological En vi ronmen t al l Monitorino Program (REMP) 16 O$-03-88 j SUSMAP-3 Process Control Program [

O2 - 11-13-84 "

l t!uclget P odugtipo_6dmlOLE!C@tlyR t ECQGedyCCM_lUE6El }

NPAP-6. Chemical Control Program 01 10-14 (

NPAP-8. Procedure Reviews 02 04-14-87 l

! NPAP-9 Radiation Protection Plan 01 01-13-87 NPAP-10 Rediation Work Permits and l

, Supplements 02, 02-29-88 i

1 1 '

1 Health _Ehystgs_Ecogedyteg_jbPE1 , l l

l HPP-1. Rout ine Sur vey Intervals and  ;

j Survov Documentation 11 '01--06-88 l j HPP-2 Bioassay Frogram 15 06-10-86 ,

i HPP-8 Radiation Surveys 06 .04-07-86 i j

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J,1 Tt, E I SSUE . NUM t<ER DATE 4 HPP-9 Establishino and Poutino Controlled g Aroan 08 05-15-86 +

HPP-11 Personnel Decon t ami ne.t 1 on 07 01-06-88 HPP-12. Portshle Asr Samolo Coliection and Analvais !1 12-15-87 HPP-13. Continuouc A1r tioni tor s 11 03-03-87 HPP-16. Soloction and Une of Reseiratorv ProtecLion Ean pment 13 07-28-87 HPP-20. Calibration of Radi at i on bet m t l un Instruments 20 03-03-87 HPP-21. Sur f ace Radi oac ti ve Cont aminati on Survevs 09 01-06-88 HPP-23. Recei vino Radi oacti ve Materi al s 10 07-29-86 HPP-25. Up of thu Health Phvsics Shiit Report and irreoularitv Rcport 07 11-25-87 HPP-26. Radioactive Mieterial Control and Handiino 16 12-22-87 HPP-27. Personnel Dosimetrv 11 08-05-86 HPP-28 Radioactive Source Lesk Testino 10 10-16-86 l

HPP-33. Fast Gas and Iodine Samplino 10 03-26-86 HPP-37 RERP Inventory List 27 05-11-88 1 1 HPP-44 Radioactive Material Spill 06 11-19-87

) HPP-45 Air Activity Analysis Using the RM 14/15 with HP210 Probe 02 12-10-82 HFP-46. Technical Specifications Related to Health Phystcs 06 07-24-86  !

HFP-48. Routine flaintenance. Inspection and C1eantno of Rr's p i r a t cr v Equipment 10 02-02-88 l HPP-49 Respirator Facepiece Fittine 06 03-17-86  !

HPP-50. Breathing Air System Samplino Frocedure 03 07-24-86 HPP-51. Continuous Air Monttors Filter end Cartridge Chance Out 08 C2-03 87 i HPP-53. RT-7325 and RT-73437 Emeroencv Filter  !

l and Cartridae Removal 05 04-01-86 HPP "$4. Conration of the Eberline BC-4 04 07-07-86

) HPP-56. Reactor building Enhaust Stock l j Discharoe Acti vity Calculation 10 05-24-88 l l HPP-58. Cal t br ation Procedure for Airflow I Measuring Devices 07 06-24-86 I HPP-61. Film Badge and Fincer Rino i

Responne Check 05 06-10-86 i

HFP-62. Portable Grab Sampler Operation i Usino 1260cc Marinelli Boaker 05 05-12-87 I HPP-63. Quantitative Respirator Fit Testino 06 11-13-85 i l

, HPP-64 Operatino the Harshaw TASC-12-A6 1 Automatic Alpha /Deta Counting System 05 01-21-87

] HPP-66. Operation of Portable Survev Instrumentation 10 03-03-87 HPP-67. Calibration and Oporation Procedure i for the Eberlino SAM-2 Stabilized 1 Assav riet er 10 12-04-86 HFP-70. Hea' th Physics Routines 06 04-13-88 2- i

4 I 1 II .tf 1SSUE NtJMBER DATfi HPf%76. ALARA 01 08-04-87 i HPP-77. Qua l i t v Rse vi ew for Health Phvu cs Documentat1on 01 03-07-88 Redi.ocimmi ery.Pt ocedorn (RCP)

F< C P - 8 . Gamole Preparation f or Tritium Analvnis 09 10-51-84 i

RCP-18. Doeration and Calibration Procedure for the Dochman LS100C 11 10-15-85 j RCP -28 Routine Laboratorv Functions 11 02-29-88 +

RCP-29 Fs a :it ol oo i ca l Sur ve111 ance Prooram 08 10-16-86

RCP-40 Operation end Calibration of the Whole Body Countano System 08 09-30-86 A Duq11ty Anutance Audtts HPH1-87-01. Health Fhysics/ Radiation Protection. tiar c h- Apr i l 1987 TROL-b8 02. Station Trainino (includino Health Physics). Januarv 1988 ,

I Qua) (t y As putenc p_ SyCvn) l ances_and_Gottegt i ye_Oqt tog _Qgqumt'Olatdpg OAC-88-0938 07-12-88 OAC-88-090S 07-06-88 OAC-88-0811 06-20-88 l OAC-88-0749 06-06-88 OAC-88-0581 05-03-08  !

OAC-88-0460 04-04-88 OAC-88-0330 03-01-88 ,

OAC-87-1157 10-23-87 OAC-87-1129 10-20-87 CAC-87-1039 09-25-87 OAC-87-0869 08-19-G7 i OAMP-OAA-05-88-04  ;

j F t). ODC- 132 j OAC-88-0831 06-23-88 i DAC-88-0314 02-19-88  ;

j OAS-88-0876  !

045-88-0739 j OAS-88-0579 j OAS-88-0423 I UAS-88-0331 [

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Nuclear T r a i n i n g _ Dep a r t men t _Et og etj pr es (TP) and Traig(OO_ECQQCemg l

< Admtnte ratt m t.1anpal_ {TEOM!

TPAM-GET. General Employee Training Program 27 01-10-86 TP-HPT. Health Physics Technician 02 05-27-87 TP-TI, Trainino Instructor 03 12-03-87

TP-Ttt. Technical Staff and Manager 01 12-03-87 j

Health Fhysics Trainino Oualification Checklist l' Traintna Record Book Category 111 GET R.etraining Student Handout. GR 614.01 1

JITLE .l SSUE _ Wit 1BER DATE Internal Expostire Contr c1. Renpa ratorv Protection Proqram Student Handout .

GE 018.03, dated Merch 22. 1988 Trainino Records for 13 FSV personnel associated with Radiation Protection Activities M tac e). l a npoy s _ Doc typ?n t s Roarcani7ation of Nuc1 ear Goeraticns. memorandum, derud flav 12, 1988 Wooroan1:ation Charts Oval i tv Assurence 11emorandum. Sub1: C)osuro of CAR 87-023 (associated with LER 87-004). Ser t al No. FPS-86-2379, dated Julv 29. 1988 Breat hiao Air System Compressoru initial functional Testu. dated January 24. 1986 (SR b.10.5a-A)

FSV Attrition Table for 1987 and 1988 Luak Test of Radioactive Sources. 1988 ALARA Committen Meetino flinutes: 02-24-88 and 03-08-88 Radiatton Work Permits:

06n61. Survov of Reflector Bl oc l<

10322. Wor k In Hot Service Facility on CRD #27 10319. Helium Circulator "B" Work (Rucker Unit) 10324. Helium Circulator "B" Work (Installation of shipping restraints)

FSV Duali ty Assurance Division Master Audit Schedule for 1987 and 1988 02 07-19-88.

Radiochemical Analvsis Report on Bioassavs for Personnel 1ritium Uptake Measurements 08-02-88 Daily Circulator Dutace Meetino Minutes: 06-29-88 and 07-28-88 Procedure Deviation Report No. 88-0647 08-09-88 FSV Memorandum. Subt: Radiation Area Postino Assumptions. Serial No.

PPC-88-2564 dated Auou3t 10. 1988 Staff Chances Checklist and Routino Sheet Attachment SUSMAP-iti. Reo Guide 1.8 Experience Reauirement Checklist for T. C. Schleiuer. dated Auoust 2, 1988 At t ac hinen t G-7A and G-7D. Plant Staff Evaluation / Qualification Form Partu 1 and 2. for T. E. Schletour. dated August 2. 1988 ,

i SR 5.4.9A-3. Area and Eauspment Radtation '

Monttor Calibration 24 03-07-85 SR 5.4.9A-4. Hioh Ranoe Containment Monitor Calibration 05 05-20-85