IR 05000320/1986007

Insp Rept 50-320/86-07 on 860616-30.Violation Noted:Failure to Adequately Survey Radioactive Core Debris Prior to Replacement in Reactor Vessel & to Follow Radiation Work Permit Instructions During Removal of Tools from Reactor

ML20203E525
Person / Time
Site:	Three Mile Island
Issue date:	07/15/1986
From:	Dan Collins, Cowgill C, Myers L, Nyers L NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:
Shared Package
ML20203E502	List: IR 05000320/1986007 ML20203E498 ML20203E513
References
50-320-86-07, 50-320-86-7, NUDOCS 8607240167
Download: ML20203E525 (6)

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. U. S. NUCLEAR REGULATORY COMMISSION Report N /86-07 Docket N License N DPR-73 Priority --

Category C Licensee: GPU Nuclear Corporation P. O. Box 480 Middletown, Pennsylvania 17057 Facility Name: Three Mile Island Nuclear Station, Unit 2 Inspection At: Middletown, Pennsylvania Inspection Conducted: June 16 - 30, 1986 Inspectors: hh D. Collins, Faciation Specialist 7 /I b[

date signed

& btdjn> > 7 l N A f0 a dite Mgned Y./Mysrs,/tadi'tiofSpecialist Approved By: [ )$sf/1 C. Co*gilQhief, TMI-2 Project Section

~7//I!fb date signed Inspection Summary: .

Inspection conducted on June 16 - 30, 1986 (Inspection Report Number 50-320/86-07).

Areas Inspecced: Special safety inspection by radiation specialists of the conduct of defueling operations and radiological controls involving the handling of small pieces of debris from the reactor core and the handling of tools being removed from the reactor vesse Results: Two violations were identified: the first violation occurred when a technician failed to adequately survey a piece of radioactive core debris prior to replacing it in the reactor vessel. The second violation involves two examples of failure to follow RWP instructions when two different defueling support teams removed tools from the reactor vesse NO $$k 0 O

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DETAILS Purpose

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This special inspection was conducted to examine the circumstances

surrounding the' handling of highly radioactive small fuel pieces of core debris unintentionally removed from the reactor vessel and the removal of tools from the reactor vessel by the Recovery Systems and Supports. On June 15 and June 17, 1986, small fuel pieces of core debris were observed on the Shielded Defueling Platform after fuel core debris handling tools were removed from the reactor vesse During the early morning of June 21, 1986, two canister handling tools were removed from the reactor vessel and stored in the tool storage rack without completing all required radiological controls instructions as required in the Radiation Work Permit. The tool removal was directed by Coordination Center Task Supervisors and completed by workers who had not read the applicable Radiation Work Permit written to cover the work activities.

, Handling of Radioactive Particles i

2.1 June 15, 1986 Event A defueling tool repair crew, consisting of a Radiological Controls Technician and two others were working in the Unit 2 reactor building on June 15, 1986. One task was to remove fuel-debris handling tools which had fallen into the reactor vessel.

. The crew removed a "j-hook" tool from the reactor vessel, and placed it on a sheet of plastic on the defueling platform. The assigned Radiological Controls Technician performed a survey and observed ,

dose rates around the bottom of the tool above the RWP allowable -

limits of 500 mR/hr gamma and 5 Rad /hr beta, and directed that the tool be placed back in the water. After the tool was replaced in the reactor vessel, the technician examined the sheet of plastic and observed a small piece of debri The technician stopped the other work on the platform, instructed workers to move away from the immediate area, and attempted to survey the piece of debris. The technician observed that the ion chamber survey instrument read off-scale high when in contact with the fuel piece. The technician was using an ionization chamber

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survey instrument and had made the survey using the 0-5 R/hr scal The technician did not attempt a reading on the 0-50 R/hr scale.

Without seeking guidance from the Coordination Center or attempting additional survey, the technician donned a pair of rubber linesman's gloves, which are provided specifically for handling items with high

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beta dose rates and using a multi-folded towel which provided

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additional protection, picked up the piece of debris and dropped it into the reactor vesse .2 June 17, 1986 Event A technician working with a tool repair team on June 17, 1986 on the defueling work platform discovered a spherical piece of core debris about 0.5 cm diameter. The piece had apparently fallen to the plastic covered platform while the tool was being repaired. The technician measured a 6 R/hr gamma dose rate at contact with the piece and a beta dose rate of 20 rad /hr at 6 inches away from the piece. After discussion by radio with the Group Radiological Controls Supervisor, located in the Coordination Center, the technician donned a heavy pair of linesman's gloves and used a piece of adhesive tape to remotely pick up the debris and place it in the reactor vessel. The inspector had no further questions regarding this even .3 Inspector Findings The inspector reviewed Radiation Work Permit (RWP) No. 14347, ALARA Review 60012 and Incident Event Report No. 320-86-51. In addition, the inspector held discussions with various technical and supervisory personnel within the Radiological Controls Departmen Based on this review, the inspector identified the following violation:

The' technician during the event of June 15, 1986 failed to obtain comprehensive radiological survey information for a small particle of reactor core debris prior to picking up the material by use of manual means. Failure to obtain a survey to evaluate the hazard associated with handling radioactive material is a violation of 10 CFR20.201(b)(2). (50-320/86-07-01)

2.5 Corrective Actions The licensee initiated corrective actions to prevent recurrence of the events described. These corrective actions were discussed with the NRC on June 17, 1986. The actions taken include performing a dose assessment for the individual involved in the June 15 event, briefing defueling workers and Radiological Controls Technicians regarding the hazards associated with fuel debris, and providing tools for remotely handling fuel particles.

4 The licensee formally described these actions in a June 23, 1986 letter to the NRC at NRC request. In addition to the above actions, the licensee indicated that this event would be covered in

Radiological Controls Department Cyclic Training. These actions will be reviewed in a future inspectio (320/86-07-02)

s The licensee performed a dose assessment to the technician's extremities. The inspector reviewed this dose assessment and found the dose assessment to be reasonable and conservative. The estimated dose to the extremity was 12 mre .

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3.0 Tool Removal from the Reactor Vessel Without Survey 3.1 Description of the Events During the night of June 20 and the morning of June 21, 1986, work activities on the Shielded Work Platform in the reactor building were directed toward preparing the Shielded Work Platform and Canister Handling System for core boring equipment. At 10:00 PM, Defueling Operations secured defueling activities on the Shielded Work Platform above the reactor vessel. Defueling Support Entry Teans were given a job briefing by Task Supervisor "A" at which time radiological conditions were discussed. Based on information the Reactor Building Group Radiological Control Supervisor received from the Task Supervisor he determined that radiological controls support would not be required in the reactor building. The Task Supervisor had explained that the work activities were to use only new tools and equipment, e.g., tools and equipment that had never been in the reactor vessel. These tools would not be contaminated; therefore, the tools and equipment would not need to be surveyed before use for dose rates. The Reactor Building Group Radiological Control Supervisor advised the Task Supervisor that before the Canister Connect Assembly was to be removed he had to have a one hour notification to provide a Radiological Control Technician on the platform to support this activity since the assembly would be highly contaminated from immersion in the reactor coolant. The Entry Teams were briefed on the fact that there would be no Radiological Control Technician on the platform since only new tools and equipment were to be used. Not all of the Task Supervisors that would later direct work activities for the Coordination Center attended the pre-job briefin .2 Tool Removal One Upon entry at 11:12 PM to the reactor building, Team I was directed by Coordination Center Task Supervisor "B" to remove the Open Canister Grappling Tool from the tool storage rack. One of the workers told Coordination Center Task Supervisor "B" that he thought only new tools were to be used. At 12:30 AM, Coordination Center Task Supervisor "C", who had relieved Coordination Center Task Supervisor "B", directed Tea'n 1 to remove the Open Canister Grappling Tool from the reactor vessel and to rinse and wipe the tool prior to storage in the tool storage rack. At 12:36 AM, the Open Canister Grappling Tool was placed in the tool storage rack without being scrubbed and surveye .3 Tool Removal Two At 5:09 AM, Team 2 entered the reactor building to complete the installation of seal covers directed by Coordination Center Task Supervisor "D". During this time another task supervisor, Task Supervisor "E" assisted Task Supervisor "D" with the work activities and at 7:40 AM Task Supervisor "E", without being properly briefed or assuming the duties of Coordination Center Task Supervisor, directed Team 2 to remove the Seal Cover Installation tool and store

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it in the tool storage rack after rinsing and wiping the tool. Task Supervisor "E" was unaware that a Radiological Control Technician was not on the platform when he directed this activity to be don Coordination Center Task Supervisor "D" was aware that Task Supervisor "E" had directed this action. The workers on the platform questioned the Coordination Center about doing this without survey but were told to proceed. The team removed the tool from the reactor vessel, rinsed and wiped the tool and stored the tool in the tool storage rack at 7:43 AM without scrubbing and surveying the tool. After exiting the reactor building, a worker told a Radiological Control Technician that tools had been removed and stored without surve .4 Inspector Review The inspector reviewed the applicable RWP and associated ALARA review, logs, applicable procedures, and documents. Based upon this review, interviews with licensee personnel and attendance at the critique, the inspector identified the following:

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Workers and engineers performing work activities.in the reactor building had not read the RWP covering the work activities, although they had signed the RW Coordination Center Task Supervisors directing work activities on the defueling platform stated that they had not read the RWP covering the work activitie Some of the Coordination Center Task Supervisors directing work activities on the platform had not attended the pre-job briefin A qualified Task Supervisor directed work activities in the reactor building without properly relieving the assigned Coordination Center Task Supervisor or making this individual aware of his intended actio Communications between Coordination Center Task Supervisors and Radiological Controls Supervisors were inadequat Specifically, information regarding tools in use and changing radiological controls requirements (removal of tools from the reactor vessel) were not accurately transmitte .5 Findings

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The GPU Nuclear Corporation Radiation Protection Plan, 1000-PLN-4010.01, Revision 1, dated May 1, 1986, states, in part, that it is an individual responsibility of each worker to obey posted, oral, and written radiological controls instructions and

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procedures, including instructions on Radiation Work Permits.

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Radiation Work Permit Number 14372 instructions required, in part, that all tools and equipment removed from the reactor vessel shall be scrubbed, wiped, and surveyed prior to relocation to the repair or storage are On two separate occasions on June 21, 1986, involving different canister handling tools, Coordination Center Task Supervisors, work teams, and Reactor Building Group Radiological Control Supervisors, there was a failure to observe the instructions on the Radiation Work Perm 1t regarding the scrubbing and survey of tools removed from the reactor vessel and stored in the tool storage rac This is a violation of Technical Specification 6.11 of Appendix (320/86-07-03)

3.6 Corrective Actions As a result of the events of June 21, 1986, and a meeting with NRC representatives on June 24, 1986, the licensee agreed to assuring that all personnel working in radiologically controlled areas would read and understand the applicable Radiation Work Permit and that Task Supervisors would be made aware of their responsibilities concerning prejob briefings, task turnover, and the requirements of Radiation Work Permits. Additionally, the licensee stated that a Radiological Control Technician would be present in the reactor building when tools or equipment are removed from the reactor vessel. In addition, the licensee agreed to formally describe immediate corrective action to the NRC. This was accomplished by letter dated July 3, 1986. The inspector will review these corrective actions in future inspection (320/86-07-04)

4.0 Persons Contacted T. Demmitt, Deputy Director, TMI-2 J. Hildebrand, Radiological Controls Director, TMI-2 C. Hultman, Deputy Manager, Defueling Group 0. Lake, Manager, Defueling Support K. Pastor, Defueling Operations Director R. Rogan, Director, Licensing & Nuclear Safety, TMI-2 F. Standerfer, Vice President / Director, TMI-2 The inspectors also interviewed other workers and supervisor .0 Exit Interview The inspectors met periodically with licensee representatives to discuss inspection findings. On July 2, 1986, the inspectors summarized the inspection findings at an exit meetin At no time during the inspection was written material provided to the licensee by the inspectors.