IR 05000213/1986022

Enforcement Conference Rept 50-213/86-22 on 860903.Major Areas Discussed:Findings of Rept 50-213/86-22 Re Radiation Protection Program Breakdowns Which Resulted in Worker Exceeding Whole Body Radiation Exposure Limit

ML20210F809
Person / Time
Site:	Haddam Neck File:Connecticut Yankee Atomic Power Co icon.png
Issue date:	09/16/1986
From:	Lequia D, Shanbaky M NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:
Shared Package
ML20210F770	List: IR 05000213/1986022 ML20210F764
References
50-213-86-22-EC, NUDOCS 8609250282
Download: ML20210F809 (15)

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U.S. NUCLEAR REGULATORY COMMISSION

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REGION I

Report N Docket N License No. DPR-61 Priority -

Category C Licensee: Connecticut Yankee Atomic Power Company P.O. Box 270 Hartford, Connecticut Facility Name: Haddam Neck Nuclear Power Plant Meeting At: Region I Office, King of Prussia, PA Meeting Conducted: SepMmber3,1986 Prepared by zzax,q 0.~LeQuia,Ah h

on Sfecialist 9 -/6 -6(.,

date Approved by: #5 M. Shanbaky, Chief, FaciTities Radiation 9[///f/[

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date Protection Section Meeting Summary: An Enforcement Conference was held at NRC Region I Offices on September 3, 1986, to discuss the findings of NRC Inspection No. 213/86-2 This inspection described several radiation protection program breakdowns which resulted in a worker exceeding the NRC quarterly whole body radiation exposure limit. This meeting was attended by NRC and licensee managemer.t. The licensee presented background and supplemental information concerning the events leading to the overexposure and also described immediate and long-term corrective actions.

8609250282 860'718 PDR ADOCK 05000213 G PDR-l l

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Details 1.0 Participants 1.1 Connecticut Yankee Atomic Power Company E. Mroczka -

Vice President, Nuclear Operations R. Graves -

Station Superintendent, Haddam Neck J. Ferguson -

Superintendent, Operations R. Rothen -

Superintendent, Generation and Construction J. Ashburner -

Supervisor, Generation and Construction R. Kacich -

Licensing Supervisor C. Palmer -

Staff Engineer W. Nevelos -

Radiation Protection Supervisor 1.2 NRC J. Allan -

Deputy Regional Administrator T. Martin -

Director, Division of Radiation Safety and Safeguards W. Kane -

Director, Division of Reactor Projects R. Bellamy -

Chief, Radiological Protection Branch E. McCabe -

Chief, Reactor Projects Section M. Shanbaky -

Chief, Facilities Radiation Protection Section J. Gutierrez -

NRC Regional Counsel D. Holody -

Enforcement Specialist D. LeQuia -

Radiation Specialist T. Weadock -

Radiation Specialist -

M. Kray -

Reactor Engineer 2.0 Introduction The Enforcement Conference was held at the request of NRC Region I manage-ment to discuss the apparent violations identified during Inspection 86-2 The discussion at this conference focused on the apparent violations; their significant, cause, and licensee initial and long-term corrective action .0 Discussion Following introduction of personnel at the conference, NRC personnel presented a brief summary of their understanding of the events which lead to the occupational whole body exposure to a Connecticut Yankee contract worker in excess of NRC quarterly limit Af ter presenting this summary the Licensee was asked to provide their perception of the event, any additional qualifying information, and their corrective actions, both initial and long-term, to prevent recurrenc __- . . - . - _ - - - _ - - _ - - _ _--.

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Details 2 4.0 Licensee Presentation The ' licensee's presentation included a summary of the events leading to the overexposure, which was detailed in a handout (see attached). The licensee then presented the results of their investigation as to the root cause of the incident. Procedural noncompliance was identified as the underlying cause of the event. Immediate and long-term corrective actions, as well as a review of any generic implications, were discussed and are included in the handou The licensee concluded that their findings were in general agreement with those of the NR .0 NRC Response Senior NRC management did not concur with tne licensee's identification of a single root cause for this event. Previous NRC inspections had identified additional examples of failure to provide effective radiologi-cal coverage for high dose rate activities. In light of this apparent declining trend, the licensee was requested to re-evaluate the causes of the incident, considering, but not limited to the following:

adequacy of Health Physics technician training, use and sensitivity to stay-time calculations,

effectiveness of direct surveillance personnel, and clarification of " intermittent" and " periodic" surveillance i requirement .0 Conclusion Licensee Senior management agreed to re-evaluate the event, considering additional potential causes. NRC Region I management stated that the licensee would be informed of the enforcement action addressing the over-exposure of the worker at a later dat .

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. ATTACHMENT

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CONNECTICUT YANKEE ATOMIC POWER COMPANY * * * * *

Haddam Neck Plant September 3,1986 Enforcement Conference Radiation Protection Program

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Radiation Protection Program September 3,1986

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Description of Event . . . . . . . . . 1 Chronology of Events . . . . . . . . 2 Roo t Cause . . . . . . . . . . . . . . . . 3 Immediate Corrective Actions . . 4 Long-Term Corrective Actions . . 5 Generic Implications . . . . . . . . . 6 Su m mary . . . . . . . . . . . . . . . . . 7

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DESCRIPTION OF EVENT

,, By way of background, in July of 1986 a corporate decision was made to

- maintain the unit in a shutdown condition to resolve steam generator tube integrity concerns. Resolution of this issue required the plugging of a number of steam generator tubes, which required a variety of activities in radiation area A brief sequence of events associated with the incident of concern is as follows:

The man involved was performing channel head camera manipulations in support of the post plugging hydrostatic test of Steam Generator No. 4. His available exposure on the RWP was 380 mrem. He was working on the elevated platform directly below the manways for a period of about 2% hours during which time he made at least four half-body jumps (1 minute, 40 seconds) into the channel hea The radiation field on the platform varied in intensity from 250 mrem / hour to greater than 1 Rem / hour (directly in front of the manways). The radiation field in the channel head exceeded 10 Rem / hour and was probably closer to 20 Rem / hour where the individual's head was during the half jumps. The individual was called off the platform by the Health Physics technicians after about th hours of work in order to read a PIC that had been taped to the exterior of his bubble hood. This PIC was found to be missing. The Health Physics technician decided to allow the man to return to work without reading the PIC that was located inside the man's bubble hood. At this point, they did not know the individual's dose. The man returned to work for about another hour. When he was removed from his plastics and his PIC was read, it was discovered that he had received about 1,700 mrem during the incident, or about 800 mrem more than his allowable. The individual, his supervisor, H.P. supervisor, and station management were notified immediately. The TLDs were sent to Berlin for expedited readout. They' confirmed that the overexposure had occurre f

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CHRONOLOGY OF EVENTS

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(all times approximate)

7/23/86 03:00 -

Worker enters S/G on RWP #864038 04:00 -

Attempt made to read PIC; PIC on outside of bubble to hood missing, and decision made to allow worker to 04:30 resume wor :30 -

Radiation Protection Supervisor notified by Senior Health Physics Technician covering S/G jo :30 -

Station services superintendant notified; additional ALARA controls institute :00 - 09:30 -

Requested expedited readout of worker's TLD; plant management and NRC inspectors made aware of event; requested independent investigation by corporate in-vestigation tea :50 -

TLD results verified exposure of 3292 mrem total for worker. CY Health Physics Technician and Contractor Technician relieved of radiological protection dutie Plant Information Report (PIR) and Radiological inci-dent Report (RIR) generate :00 -

NRC and State of Connecticut informed of event via ENS call and radiopager message as a general interest even /23 - 7/25/86

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NRC resident and onsite inspection team kept appraised of ongoing event NRC inspectors conducted investigation through inter-views with involved worker American Nuclear Insurers (ANI) notified of even /20/86

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Licensee event report submitted to NRC (copy attached).

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ROOT CAUSE

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. The func'. mental reason why this event occurred was the failure to follow

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established procedures. Specifically, Procedure ACP 1.0-4, Radiation Work Permit Completion and Flow Control, was not adhered to.

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l IMMEDIATE CORRECTIVE ACTIONS Health Physics technicians involved were relieved 7/23/86 from all radiation protection dutie The Health Physics technicians were discipline /23/86 Platform workers were required to wear 7/23/86 self-alarming dosimeter Health Physics technicians who are upgraded 7/23/86 will not provide direct job coverage unless so instructed by Health Physics supervision. (The upgraded technician will oversee work activities within his/her assigned zone.)

Job supervision and the Health Physics Technicians 7/24/86 assigned steam generator responsibilties will have a prejob discussion including job scope and goals to be achieved prior to the start of wor The Station Superintendant issued notices informing 7/25/86 all workers of the event and reinforced the requirement to follow station procedures.

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LONG-TERM CORRECTIVE ACTIONS Health Physics technicians shall be trained in skills of work direction. Practical training exercises will be implemented and will be an integral part of our re-training program. . The overexposure event will be part of the " Lessons Learned" re-training for all Northeast Utilities Health Physics technician CYAPCO's approach to eliminate procedure violations will be strengthene The approach listed below will be presented to all employees to ensure understanding of our commitment . Training: New employee training and indoctrination emphasizes the importance of procedure understanding and compli-anc . Notices: The distribution of station memos to all employees on a routine basis will ensure an awareness of the importance of procedure complianc . Discipline: CYAPCO will emphasize procedure compliance by en-forcement of CYSP-94, entitled Disciplinary Actio The requirement to follow procedures will be emphasized with all plant employees. The plant disciplinary action policy will be reviewed with plant employees and the policy will be uniformly and consistently applied in future instances of failure to follow procedure l l

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GENERIC IMPLICATIONS CYAPCO reviewed other plant performance indicators (Plant Information Reports, SALP Reports and NRC I & E Reports) in an attempt to identify any generic problems with procedural compliance (the root cause of this event).

Particular attention was focused on the level of procedural compliance achieved in those areas where Connecticut Yankee received a SALP Category I ratin CYAPCO has concluded that there is a direct relationship between these performance results and the level of procedural compliance present in a given area. Generally speaking, those areas where CYAPCO has consistently done well have been characterized by a high degree of procedural compliance. The converse is also true, as illustrated by this even Based on this generic review, CYAPCO's management has resolved to strictly enforce Station Policy 94 (Disciplinary Action). A signal will be sent to all employees and contractors that procedural compliance is expected, and that failure to comply will result in disciplinary action.

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SUMMARY

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CYAPCO acknowledges that an exposure in excess of 10CFR20.101(b)(1) limits did occu The event was promptly identified and reported to first line supervision, plant management, corporate management, and State of Connecticut and NRC official The event was promptly and thoroughly investigated by:

o Plant Management o Corporate Investigation Team o NRC o INPO A thirty day LER was prepared and submitted on August 20,198 Immediate corrective action was taken to avoid further repetition of the inciden The long-term cc rective actions are comprehensive, with a broad focus over the entire plant orgmizatio Long-term actions to prevent recurrence are structured to send a signal to all employees and contractors that failure to follow procedures will be dealt with seriously, and disciplinary action will be consistently applied at the Haddam Neck Plant.

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CONNECTICUT YANKEE ATO MIC POWER COMPANY HADDAM NECK PLANT RR#1 * BOX 127E * EAST HAMPTON, CONN. 06424 August 20, 1986 SS86-190 U.S. Nuclear Regulatory Commission Document Control Desk Washington, D.C. 20555 Reference: Facility Operating License No. DPR-61 Docket No. 50-213 Reportable Occurrence LER 50-213/86-039-00 Gentlemen:

This letter forwards the Licensee Event Report 86-039-00, required to be submitted within 30 days, pursuant to the requirement of Connecticut Yankee Technical Specification Very truly yours,

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Richard H. Graves Station Superintendent RHG Attachment: LER 86-039-00 cc: Dr. T. E. Murley, Region I

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<.,,,,- ,n During repair of a steam generator on July 23, 1986, a worker was assigned to position a video camera to better view a hydrostatic test. This worker spent a total of two hours and forty minutes in the skirt area of the steam generato The senior Health Physics technician noted that the PIC was missing from the workers bubble hoo skirt area. Upon exiting A decision was made to allow the worker to reenter the the PIC located under the bubble hood was read and was found to read 1.7 rem. This resulted in a total whole body exposure of 3.29 re which is in excess of the quarterly limit specified in 10CFR2 EVENT DESCRIPTION The man involved was performing channel head camera manipulations in support of the post plugging hydrostatic test of Steam Generator No. 4. His available exposure on the RWP was 880 mre directly below the manways for a period of about 2He was hoursworkingduring on whichthe timeelevated he platform made channel hea at least four half-body jumps for a total of 1 minute, 40 seconds into the The radiation field on the platform varied in intensity from 250 mrem / hour to greater than 1 Rem / hour (directly in front of the manways). The radiation field in the channel head exceeded 10 Rem / hour and was probably closer to 20 Rem / hour where the individual's head was during the half jumps. The individual was sa' 7s5

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called off the platform by the Health Physics technicians after about I hours of work in order to read a PIC that had been taped to the exterior of his bubble hood. This PIC was found to be missing. The Health Physics technicians decided to allow the man to return to work without reading the PIC that was located inside the man's bubble hood. At this point they did not know the individuals dose. The man returned to work for about another hour. When he was removed from his plastics and his PIC read, it was discovered that he had received about 1,700 mrem during the incident or about 800 mrem more than his allowable. The individual, his supervision, and station management were notified immediately. The TLDs were sent for expedited readout. They confirmed that the overexposure had occurre REPORTABILITY This event is reportable under 10CFR20.405(a)(1)(1)

ROOT CAUSE The root cause for this event is that the Health Physics technician failed to follow approved radiological control procedure CORRECTIVE ACTION The Health Physics technician ,;as relieved of radiological protection duties and will not be allowed to resume them until he undergoes a requalification process. Additional details concerning Licensee response to this event will

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be contained in the response to I&E Inspection 50-213/86-2 .

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