IR 05000317/1997002

Discusses Insp Repts 50-317/97-02 & 50-318/97-02 on 970302- 0412 & 50-317/97-03 & 50-318/97-03 on 970413-0531 & Notice of Violations & Proposed Imposition of Civil Penalty in Amount of $176,000

ML20210K642
Person / Time
Site:	Calvert Cliffs
Issue date:	08/11/1997
From:	Miller H NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Cruse C BALTIMORE GAS & ELECTRIC CO.
Shared Package
ML20210K648	List: ML20210K642 ML20210K651
References
50-317-97-02, 50-317-97-03, 50-317-97-2, 50-317-97-3, 50-318-97-02, 50-318-97-03, 50-318-97-2, 50-318-97-3, EA-97-192, NUDOCS 9708200004
Download: ML20210K642 (6)

Text

d

. .

'

easeg ka UNITED staffs j s

[ NUCLEAR REOULATORY COMMISSION nacioN I

!

l 4M ALLENoAlt hoAD  :

l KING oF PMusstA PENNSYLVANIA 1H061415

e.. * l

. August 11,1997  !

i EA 97192 i

Mr. Charles Vice President . Nuclear Energy t Baltimore Gas and Electric Company (BGE)  !

Calvert Cliffs Nuclear Power Plant 16bs Calvert Cliffs Perkway Lusby, Maryland 20067 4702 SUBJECT: NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTIES

- $176,000 (NRC Inspection Reports Nos. 50 317/97 02 & 50 318/97-02; ,

50 317/97 03 & 60 318/37 03)  ;

,

Dear Mr. Cruse:

'

This letter refers to the NRC inspection conducted at the Calvert Cliffs Nuclear Power Plant

'

from March 2,1997 to April 12,1997 and on April 24,1997, the findings of which were provided to you during inn exit meeting on May 7,1997. The inspection report was sent to

'

you on May 29,1997. During the inspection, several apparent violations were identified, including a number of violations related to the f allure to effectively control activities conducted

,

by a contractor diver in the Unit 2 spent fuel pool. Other apparent violations, related to .

inadequate rediation protection controls, as well as inadequate fuel handling operations, were

'

!'

'

also identified. On June 12,1997, a Predecisional Enforcement Conference was conducted with you and members of your staff to discuss the violaticns, their causes, and your corrective !'

actions. During the conference, two examples of an additional apparent violation of

radiological protection program requirements were also discussed. Those additional apparent violations, which were identified by your staff,were reviewed by the NRC during an inspection conducted between April 13,1997 to May 31,1997, for which an exit meeting was held on June 19,1997. That inspection report was sent to you on July 1,1997.

Based on the information developed during the inspections, and the information provided

'

durbg the enforcement conference, thirteen violet'ons of NRC requirements are being cited and are described in the enclosed Notice of Violation and Proposed imposition of Civil t Penalties (Notice). The three moat significant violations relate to the failure to implement appropriate radiological controls during the diving operations in the Unit 2 spent fuel pool, ;

resulting in the potential for a diver to gain unauthorized or inadvertent access to very high r

radiation areas that could have resulted in significant radiological exposure to the individual, t Specifically, due to insufficient controls, inadequate pre job planning and communication, ineffective surveillance of the diver, and deficient supervisory oversight of the activity, the

' '

ind!vidual was inadvertently able to gain access to areas in which radiation levels could be .

encountated at 500 rods or more in an hour due to the proximity of spent fuel.

_

{

ED[

G k ob17 PDR

<g--h'( !

,

!

- - - - - - __- ---

- - . - _- .. -

'

,

Baltimore Gas and Electric Company 2 The specific violations associated with the diving activity involve (1) f ailure to ensure that the diver would not be able to gain unauthorized or inadvertent access to areas where radiation levels could be 600 tads or more in an hour; (2) f ailure to provide adequate instructions to the diver as to the nature and location of very high radiation fields and the authorized work tasks; and (3) f ailure to perform adequate surveys during and af ter the diver entered an area of the spent fuel pool that had not boon previously surveyed. .our radiological control staff,

'

responsible for plannint; and mNitoring this activity, failed to provide control of this activity sufficient to assure thei the dives would not be unexpectedly exposed to, or inadvertently enter, very high radiatko fields within the spent fuel storage pool.

This event occurred during the fourth of five dives into the Unit 2 refueling cavity and spent fuel pool in April 1997 to inspect and repair malfunctioning fuel transfer equipment. During the fourth dive, the diver lef t the previously surveyed and approved dive location at the south end of the Unit 2 spent fuel pool, and moved into an unapproved, unsurveyed area ln the north end of the pool. in doing so, the diver entered areas exhibiting significantly higher radiation fields, where he received an unplanned radiation exposure, and could have been occupationally exposed in excess of regulatory limits.

The fundamental controls provided to ensure that the diver could not gain unauthorized or inadvertent access to very high radiation fields were inadequate. Even though the diver was equipped with a tether, the individual monitoring the tether did not question the excessive amount of restraint fSat was let out as the diver traversed to the unsurveyed north end of the pool. While the diver was provided with multiple personal dosimetry devices that were remotely monitored by the radiation protection technicie7s, he was not continuously monitored by a television camera, as he had been during previous dives. Instead, the radiation protection personnel were expected to provide continuous coverage via a viewing glass placed on the surface of the pool. However, such coverage was flawed in that bubbles from the divera breathing air and to some degree, the refueling bridge, obscured direct observation. Also, the individual responsible for maintaining direct visual contact, by your own admission at the enforcement conference, became distracted from his responsibilities. As a result, the radiation protection personnel failed to observe the diver move away from the approved location.

Further, when the dosimetry readouts indicated that the diver was being exposed to higher than expected fields, rather than confirming his whereabouts, the diver was inappropriately directed to reenter the area to locate the source of the radiation, h addition, the prejob briefing with the diver and dive support personnel was ineffective in that a late change in the scope of the work directly resulted in the diver's misunderstanding of the work scope. Also, the radiation survey briefing at the job site did not identify to the diver the radiological hazard associated with the fresh irradiated fuelin'the north end of the pool in that the diver was provided with a survey map of the south end of the pool, which he interpreted as representing the entire pool. Moreover, the diver was unaware that he was restricted from performing any activities at the north end of the spent fuel pool since the area was not surveyed.

'

.

Baltimore Gas and Electric Company 3 Af ter the fourth dive was completed, but prior to processing the diver's dosimetry, a decision was made to initiate a fifth dive, using another diver to complete the repair / inspection.

Without his dosimetry first being processed to determine the exposure obtained during the fourth dive, the diver from the fourth dive was allowed to re enter the spent fuel storage pool work area to support the other diver. Although he re entered the radiological controlled area and worked in areas with low radiation dose rates, a comprehensive dose assessment had not been performed to determine whether the unauthorized entry into the unsurveyed area resulted in the diver receiving a dose in excess of the limits of 10 CFR Part 20. Preliminary calculations performed by your staff, indicated that the diver's right extremity (right knuckles) may have entered radiation fields of 155 to 310 rem /hr and the whole body (right arm) may have entered radiation fields ranging from 45 to 90 rem /hr.

Although subsequent detailed dose assessments for the diver indicated that no apparent radiation exposure in excess of NRC limits likely occurred, this was nonetheless a significant event given the serious consequences that could result from the diver being in close proximity to irradiated fuel. Weaknesses in the establishment and implementation of the type of radiological controls necessary to assure safety in the vicinity of very high radiation areas resulted in a substantici potential for an exposure in excess of regulatory limits at the f acility.

In summary, the NRC considers that the event resulted from a serious lack of attention toward licensed responsibilities. The event involved a serious breakdown in controls that were to be provided for the diving evolutions. Significant deficiencies in communications, coordination, and management oversight and decision making, also existed. As a result, a substantial and unnecessary occupational exposure nearly occurred. Therefore, the violations in Section I, which involve a very significant regulatory concern, have been classified in the aggregate as a Severity Leveill problem in accordance with Section IV of the " General Statement of Policy and Procedure for NRC Enforcement Actions " (Enforcement Policy), NUREG 1600.

In accordance with the Enforcement Policy, a base civil penalty in the amount of $88,000 lo considered for a Severity Level ll violation or problem. Also, since this is a Severity Level ll problem, the NRC considered whether credit was warranted for / dent /// cat /on and Correct /ve Act/on in accordance with the civil penalty assessment process in Section VI.B.2 of the Enforcement Policy. Credit for identification is not warranted because there were several missed opportunities during the dive to identify these problems, particularly when dosimetry first alarmed, when the technician lost visual contact of the diver because of the bubbling, and when the diver asked a technician for more line and was not questioned. Credit for corrective actions is also not warranted because the immediate corrective actions after the fourth dive were deficient in that another diver was allowed to enter the pool without having obtained a thorough understanding of the cause of the earlier "near miss". Giv'en the potential for substantial personnel exposures that could result from being in such close proximity to the irradiated fuel, a root cause analysis should have been performed before commencing the fifth dive, as you acknowledged at the enforcement conference. Additionally, even though you took action to change your radiological controlled area dive operations and formalize your job coverage standard into a radiation safety procedure, you did not adequately assess the full scope and root causes of the breakdown that occurred. For example, you did not determine the extent to which production pressure was a f actor in causing the event. Further, during the enforcement conference, you did not appear to understand all potential contributors to the event, such as the cause of the inattentiveness of the lodividual assigned to observe the diver.

l

.

.

Baltimore Gas and Electric Company 4 ,

Therefore, to emphasize the seriousness of this event, and the importance of appropriate management control and oversight of such activities, I have been authorized, after consultation with the Director, Of fice of Enforcement, to issue the encloseJ Notice of Violation and Proposed imposition of Civil Penalty (Notice)in the amount of $176,000 f or the violations in Section 1.

The remaining violations being cited are described in Sections ll and 111 of the enclosed Notice and are classified at Severity LevelIV. A number of these vlotations were identified by your staff and while a civil penalty is not being proposed for these violations, they are indicative of further programmatic weaknesses in radiological controls and protection, maintenance of refueling equipment, and conduct of refueling activities.

Two other apparent violations listed in Inspr.9 tion Report 97 02, which you identified, involving (1) the f ailure to verify that each exhaust fan maintains the spent fuel storage pool at a measurable negative pressure relative to the outside atmosphere during system operation, and (2) the refueling machine's main holst 3,000 pound overload limit being bypassed during portions of fuelmovement within the reactor pressure vessel, are not being cited because they meet the criterla in Section Vll.B.1 of the enforcement policy regarding the exercise of discretion. Further, another apparent vlotation ininspection Report 97 02, involving drawings not being used to prepare either the troubleshooting form or contingency plans during assessment and repair of the stuck refueling transfer carriage,is being withdrawn because of information you provided at the conference where it was stated that drawings were used in a parallel assessment of the event.

You are required to respond to this letter and should folicw the instructions specified in the enclosed Notice when preparing your response. The NRC will use your response, in part, to determine whether further enforcement action is necessary to ensure compliance with regulatory requirements, in accordance with 10 CFR 2.700 of the NRC's " Rules of Practice," a copy of this letter,its enclosure, and your response will be placed in the NRC Public Document Room (PDR).

Sincerely,

[ $6 Hubert J. Miller '

Regional Administrator Docket Nos. 50 317, 50 318 License Nos. DPR 53, DPR 69 Enclosure: Notice of Violation and Propoced Imposition of Civil Penalties

. _ _ - . - . . . . - - . . - .--- .-.-- .-. . - .

.-- _ _ . . - . - - . . - . - . . -

<

.

' Baltimore Oas and Electric Company 5 *

i

,

'

cc w/ encl:

T. Pritchett, Director, Nuclear Regulatory Matters (CCNPP) ,

'

4 R. McLean, Administrator, Nuclear Evaluations J. Walter, Engineering Division, Public Service Commission of Maryland K. Burger, Esquire, Maryland People's Counsel ,

R. Ochs, Maryland Safe Energy Coalition  !

State of Maryland (2)

i

i

!

l

,

a

'I I

i

,

a J

=w.e.r--orv, e..,ww=> .-eme, vr, , -- , ~,*-wr---r- r + v- --wo----r----- r -i--+-#, wet-e-w-,w-- v-e.-e+<y-- - y.w w , --

- -,

w I )

.

Baltimore Goa and Electric Company 6 ,

L

!

DIGJRIBUTION:

PUBLIC SECY CA ,

LCallan, EDO  !

'

AThadani, DEDE JLloberman, OE HMiller, RI FDavis, OGC SCollins, NRR RZimmerman, NRR Enforcement Coordinators Al, Ril, Rill, RIV BBeecher, GPA/PA GCaputo, 01 PLohaus, OSP i'

HBell, OlG Dross, AEOD TReis, OE OE:EA (Also by E Mail)

NUDOCS DScrencl, PAO RI NSheehan, PAO RI LTremper, OC Nuclear Safety Information Center (NSIC)

NRC Resident inspector . Calvert Cliffs ,

,

&

4 I

-, -~,r--m,-- . - - - . . , -. - . , , . . . . - .. - - - - ,,