JPN-87-028, Responds to NRC Re Violations Noted in Insp Rept 50-333/87-07.Corrective Actions:Prejob Briefing & Preshift Briefing Added to Radiological Sensitive Procedures & Procedures Revised to Delineate Responsibilities
| ML20214K977 | |
| Person / Time | |
|---|---|
| Site: | FitzPatrick  |
| Issue date: | 05/21/1987 |
| From: | Brons J POWER AUTHORITY OF THE STATE OF NEW YORK (NEW YORK |
| To: | NRC OFFICE OF ADMINISTRATION & RESOURCES MANAGEMENT (ARM), NRC OFFICE OF ENFORCEMENT (OE) |
| References | |
| JPN-87-028, JPN-87-28, NUDOCS 8705290130 | |
| Download: ML20214K977 (14) | |
Text
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.. 4 123 Main Street Q{
White Plains, NewWrk 10601 y
914 681.6200
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& Authority nay 21, 1987 JPN-87-028 Director, Office of Enforcement U.
S.
Nuclear Regulatory Commission Attn:
Document Control Desk Washington, D.C.
20555
Subject:
James A.
FitzPatrick Nuclear Power Plant Docket No. 50-333 Inspection 87-07 Reply to a Notice of Violation
References:
1.
NRC letter, W.
T.
Russel to J.
C.
Brons, dated April 22, 1987, transmitting a Notice of Violation.
2.
NYPA letter, R.
J.
Converse to the NRC, dated March 16, 1987 (JAFP-87-0239), transmitting Licensee Event Report 87-002-00.
3.
NRC letter, T.
T.
Martin to R.
J.
- Converse, dated March 11, 1987, transmitting Inspection Report 50-333/87-07.
Dear Sir:
This letter provides the Authority's response to the Notice of Violation contained in Reference 1.
This Notice identified several violations which occurred during an event at the FitzPatrick plant on February 13, 1987.
The event, which is described in detail in References 2 and 3, occurred during the cutting and removal of incore instrumentation dry tubes from the reactor vessel.
During this operation, the cutting tool was removed from the water for inspection.
A piece of the highly radioactive dry tube which had been stuck in the tool fell out onto the refueling floor.
A worker immediately picked up the piece of dry tube and threw it back into the water.
As a result of this brief contact with the dry tube, the worker received an instantaneous exposure of approximately 29.6 rem 1
to his hand.
This is in excess of the NRC limit of 18.75 rem / quarter for extremity exposures.
As a result of the over-exposure, the NRC issued the Notice of Violation in Reference 1.
The Notice of Violation is repeated below and is followed by the Authority's response.
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..w Notice of Violation and Proposed Imposition of Civil Penalty a
A.
10 CFR 20.101(a) limits the total occupational radiation exposure to the hands of an individual in a restricted area to 18.75' rem per calendar: quarter.
Contrary to the above, during the first calendar quarter of 1987, a contractor individual working on the refuel floor, a restricted area, received a-total occupational radiation exposure to the right hand of approximately 30.27 rem, of which 29.6 rem was received on February 13, 1987 while the individual 2
was performing an activity associated with the cutting of Source Range Monitor (SRM) and Intermediate Range Monitor (IRM) instrument dry tubes.
B.
10 CFR 20.201(b) requires that each licensee make such surveys.
as may be necessary to comply with all sections of Part 20.
As i
defined in 10 CFR 20.201(a), " survey" means an evaluation of the radiation hazards incident to the production, use, release, disposal, or presence of radioactive materials or other sources i
of radiation under a specific set of conditions.
Contrary to the above, on February 13, 1987, adequate surveys j
were not performed to assure compliance with 10 CFR20.101(a),
which~1imits the radiation exposure to the extremities in any i
i calendar quarter.
Specifically, 1.
workers removed a cutting tool from the refueling pool and placed it on the refuel floor without a survey or evaluation first being performed to determine the radiological hazards i
associated with removal of the cutting tool.
- Further, although a survey of the tool was performed after it was l
removed from the pool, the survey was inadequate in that it only detected an exposure rate of 2.1 R/hr, when in fact the j
actual exposure rate, as determined during a subsequent survey, was 16,300 R/hr.
As a result, when a worker picked 4
up a piece of highly irradiated dry tube that fell from the tool, he received an extremity exposure in excess of the regulatory limit; and t-2.
the worker who received the exposure set forth in violation A subsequently began to repair the dry tube cutting tool without the Radiation protection technician having first performed a survey of the tool.
(Surveys conducted on the i
previous shift indicated that " chips" with exposure rates'as high as 415 R/hr. had been found in the tool).
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1 C.
10 CPR 19.12 requires, in part, that all individuals working in a restricted area be instructed in the precautions and procedures to minimize exposure to radiation and radioactive materials, and in the applicable provisions of the Commission's regulations and licenses.
Contrary to the above, on February 13, 1987, 1.
a contractor worker removing an instrument dry tube cutting tool from the refueling pool, a restricted area, had not been instructed in the proper procedures to follow if a segment of highly radioactive dry tube remained in, or fell from, the tool; and 2.
two Radiation Protection technicians providing job coverage for dry tube cutting operations in the restricted area, had not been provided a pre-job briefing of the work they were covering, nor were they provided instructions, as described in procedure RAP 7.1.23 " Removal and Installation of IRM/SRM Instrument Dry Tubes," concerning the radiological precautions to be taken in covering such activities.
D.
Technical Specification Section 6.8(A) requires that written procedures be established, implemented and maintained covering the requirements and recommendations referenced in Appendix A of Regulatory Guide 1.33 (1972).
Appendix A of Regulatory Guide 1.33 recommends that the Bypass of Safety Functions and Jumper Control be covered by written procedures.
Procedure WACP 10.1.3, entitled " Jumper Control", Step 4.12, defines a jumper as the removal of an electrical wire from a circuit,and requires in part, that jumpering be properly identified, authorized, recorded, and periodically reviewed.
Contrary to the above, as of February 13, 1987, and for an undetermined period of time prior to this date, a jumper which defeated the Area Radiation Monitor (JB-ARM-7) alarm horn was removed without the jumper being authorized or recorded as required.
E.
Technical Specification Section 6.11 requires, in part, that procedures for personnel radiation protection shall be prepared and adhered to for all plant operations.
1.
Procedure RPOP-4, entitled " Radiation Work Permit," Section 4.9.3.d, requires, in part, that the leadman ensure that all personnel working on the RWP comply with all dosimetry and protective clothing requirements.
RWP 87-2099-S, dated February 13, 1987 requires that high range (0-500 mrem) direct reading dosimeters be worn during dry tube cutting activities.
Contrary to the above, at about 8:00 a.m. on February 13, 1987, the leadman for RWP 87-2099-S did not ensure that all personnel complied with the dosimetry requirements set forth in the RWP.
Specifically, three of the six workers that signed in on RWP 87-2099-S performed dry tube cutting activities without wearing a high range direct reading dosimeter.
2.
Procedure RPOP-7, entitled " Radiological Incident Inves tigations ", Section 4. 2, requires, in part, tha t whenever a radiological incident occurs, Radiological and Environment Services (RES) Department personnel shall stop associated work and notify RES Supervision.
Contrary to the above, at about 9:00 a.m. on February 13, 1987, a radiological incident occurred on the refuel pool involving a contractor worker receiving a radiation overexposure to his right hand, and RES Department personnel allowed work to continue for approximately one and one-half hours before notifying RES Supervision.
Collectively, these violations have been classified as a Severity Level III problem.
(Supplement IV)
Cumulative Civil Penalty - $75,000 - assessed equally among the violations.
Response
The Power Authority agrees with the findings specified in the Notice of Violation.
A comprehensive review of the incident was performed by senior site and corporate personnel to identify the reasons for the overexposure including: the direct causes; weaknesses which could have indirectly contributed to the event; and, weaknesses which could affect other work.
As discussed at the enforcement conference on March 25, 1987, a number of problem areas were identified as contributors to the overexposure incident. identifies each problem area, the violation (s) to which it contributed, and the short and long term corrective actions being taken to prevent recurrence.
It is arranged by problem areas rather than violations since several of the problem areas contributed to more than one violation.
The short term corrective actions have been completed and full compliance has been achieved.
The long term corrective actions to preclude recurrence of this incident will be fully implemented by the dates given in Attachment 1.
Civil Penalty.
Should your or your staff have any questions, please A check in the amount of $75,000 is ~ enclosed as payment of the contact Mr. J.
A. Gray, Jr.'of my staff.
Very truly yours, w-John C.
Brons Executive Vice President Nuclear Generation STATE OF NEW YORK COUNTY OF WESTCHESTER Subscribed and sworn to before me this A/-4/ day of 1987.
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Office of the Resident Inspector du7 6 /3 /, /1#1 U.
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Nuclear Regulatory Commission P.
O. Box 136 Lycoming, New York 13093 U.
S. Nuclear Regulatory Commission Region I 631 Park Avenue King of Prussia, PA 19406 Mr. Harvey Abelson Project Directorate I-l Division of Reactor Projects-I/II U.S. Nuclear Regulatory Commission 7920 Norfolk Avenue Bethesda, Maryland 20014
ATTACHMENT 1 PROBLEM / CORRECTIVE ACTION MATRIX 1.
PROBLEM:
MULTIPLE COMMUNICATIONS BREAKDOWN o
No pre-shift briefing was held even though a 400R/hr chip was encountered on the previous shift.
o Radiation protection technician was not aware a dry tube had been cut.
o Supervisors were not made immediately aware that a serious incident had taken place on refuel floor.
Violations:
C, E
Short Term Corrective Action:
Requirements for pre-job briefing and pre-shift briefing were added to radiologically sensitive procedures as the jobs were scheduled during the outage.
Training was accomplished by management staff for leadman and self monitors relative to " lessons learned" from this incident.
Training was held for the dry tube crews prior to allowing work to resume.
Result:
These actions have increased worker awareness of radiological hazards and improved supervisor-worker and worker-worker communications.
Long Term Corrective Action:
A pre-job briefing check-off sheet, including guidance on when it is required, has been developed.
Training is incorporating " lessons learned" from this incident into General Employee Training, radiation protection technician training, contractor technician training and operator training.
These items will be implemented by July 31, 1987.
2.
PROBLEM:
POORLY DEFINED AUTHORITIES o
The refuel floor supervisor did not direct the radiation protection technician to perform a proper survey, o
The refuel floor supervisor did not stop the reactor service technicians from hoisting the cutting tool from the water.
o The refuel floor supervisor did not stop the job following the incident.
The radiation protection technician did not stop the job or o
perform a proper survey.
Violations:
A, B, E
Short Term Corrective Action:
The specific procedures were revised delineating the authorities and responsibilities of the refuel floor supervisor and the radiation protection technicians.
In pre-job training sessions, the dry tube work crews were instructed on these authorities and responsibilities.
The' radiation workers of the plant staff were trained in the lessons learned relative to this incident.
Result:
The combination of procedure revisions and additional training have resulted in clear delineation of responsibilities.
Long Term Corrective Action:
A procedure review check-off sheet has been generated to be used when a new procedure is written and when performing the periodic review (two years) of existing procedures.
This check-off list questions the adequacy of radiological hold points and precautions for the given procedural evolution.
As specified before, a pre-job briefing check-off list has been developed.
Training materials are being revised to address the lessons learned from this incident.
These will be implemented by July i
31, 1987.
3.
PROBLEM:
FAILURE TO PROPERLY SURVEY o
Tool was not surveyed prior to leaving water.
Tool was not surveyed prior to blade inspection.
o Violations:
A, B Short Term Corrective Action:
The cutting tool procedure was revised to include radiological hold points.
The refuel floor radiological monitoring procedure was revised to require monitoring of the cutting tool with an extendable probe instrument as it leaves the water.
Pre-job training for the dry tube crews stressed the importance of performing appropriate and timely surveys.
2
Result:
The failure to properly perform surveys has been corrected by procedural revisions and additional training.
Long Term Corrective Action:
Training materials for radiation protection technicians are being revised to provide instruction on appropriate and timely surveys.
This change will be implemented by July 31, 1987.
The refuel floor radiological monitoring procedure was revised to require monitoring of potentially highly contaminated or activated material, as it leaves the water, with an extendable probe instrument.
4.
PROBLEM:
FAILURE TO FOLLOW PROCEDURES o
Some of the workers on the refuel floor did not have on 0-500 mR direct reading dosimeters.
o The cutting tool was not surveyed as it was hoisted from the water or prior to inspecting it.
o The work was not stopped nor was RES supervision natified.
o The RWP required a preplan meeting which was not held, o
The disconnected audible alarm associated with the area radiation monitor was not entered in the jumper log.
o RWP leadman did not ensure personnel were complying with the RWP.
Violations:
A, B, D, E Short Term Corrective Action:
Preplan meetings were held with all personnel prior to resuming the dry tube job.
Requirements for following procedures were stressed.
As an interim step, radiation work permit leadman responsibilities are summarized and require the leadman's signature prior to his receiving a radiation work permit.
The refuel floor procedure for dry tube replacement was revised so that area radiation monitors are tested once per shift.
Result:
These actions have made workers more aware of their responsibility to follow procedures.
Long Term Corrective Action:
Training materials are being revised to address lessons learned from this incident.
They will be implemented by July 31, 1987.
3
A long term program to re-emphasize radiation work permit lead-man responsibilities and ensure compliance is being developed and will be implemented by July 31, 1987.
A standing order has been issued which requires RES supervisors to monitor and review radiological sensitive jobs for procedural compliance.
This procedure was implemented on March 4, 1987.
The surveillance test for ARMS has been revised to verify that local alarm units in ARMS are properly connected.
This incident was discussed with the radiation workers on the plant staff.
Personnel were informed that RWP violations will be vigorously pursued and disciplinary actions taken where necessary.
Over the past two months, six individuals have been l
subject to disciplinary action.
5.
PROBLEM:
INADEQUATE TRAINING o
Personnel did not understand the magnitude of the sources associated with irradiated components.
o Personnel were not aware of the radiological precautions
)
associated with the dry tube cutting procedure, o
The radiological supervisor and radiological technicians had limited experience with the radiological problems associated with dry tube cutting.
Violation:
C Short Term corrective Action:
Dry tube cutting procedures were revised to warn workers of possible hazards.
Pre-job training of dry tube work crews was conducted.
The radiation workers of the plant staff were trained on the lessons learned relative to this incident.
Result:
Procedural revisions and additional training have increased worker awareness of radiological hazards.
Long Term Corrective Action:
The pre-job briefing check-off sheet has been developed to address hazards of work evolutions.
Training materials are being revised to address lessons learned from this incident.
This training will be implemented by July 31, 1987.
4
o.
6.
PROBLEM:
INADEQUATE PROCEDURES o
Dry tube cutting procedures did not contain specific hold points.
o procedures did not clearly delineate authorities and responsibilities.
o Procedures did not address response to alarms, o
ALARA review did not address "what if" scenarios, o
Procedure did not require a high range extendable probe survey instrument.
Violation:
E Short Term Corrective Action:
The dry tube cutting procedure was revised.
The procedures involving refuel floor work were revised prior to the work being performed.
Result:
These actions have increased the effectiveness of procedures in protecting workers against radiological hazards.
Long Term Corrective Action:
A procedure review check-off procedure was developed to give appropriate guidance to procedure reviewers relative to hold points, radiological precautions, alarm responses, and authorities and responsibilities.
Procedures which govern "ALARA" reviews have been revised to include an evaluation of potential radiological conditions.
7.
PROBLEM:
INAPPROPRIATE SELECTION OF RADIOLOGICAL SURVEY INSTRUMENTS o
A high range extendable probe instrument was not in use on the refuel floor during this accident.
Violation:
B Short Term Corrective Action:
The appropriate refuel floor radiological procedure was revised to require the use of an extendable probe high range survey meter for removal of tools and equipment from water.
Result:
This procedural revision assures that appropriate survey instruments will be used.
5
Long Term Corrective Action:
The appropriate radiological survey techniques procedure has been revised to expand guidance on use of extendable probe high range instruments.
Radiation protection technician training will be revised to ensure adequacy of survey instrument selection.
This will be implemented by July 31, 1987.
8.
PROBLEM:
FAILURE TO IMPLEMENT PREVIOUSLY IDENTIFIED CORRECTIVE ACTIONS Inspection 85-12 cited the facility for not doing a proper o
survey when the dry tube cutting tool was removed from the water.
A memo was generated to correct this finding for the short term.
However, the procedural revisions required to preclude recurrence were not generated.
Violations:
A, E
Short Term Corrective Action:
The refuel floor radiation protection coverage procedure was modified to meet the intent of the original commitment.
Radiological hold points were incorporated into the procedure for dry tube cutting to meet the intent of the original commitment.
I Result:
These actions have fully implemented previously identified corrective actions.
i Long Term Corrective Action:
A site action commitment tracking system was revised about 1 year ago; unfortunately, the Inspection 85-12 open items had already been closed.
The new system is maintained by the i
Superintendent of Power and to date appears to be working very well.
QA will audit all future violation responses, licensee event reports and bulletin responses to ensure commitments are met.
QA will also review the sane items from 1984 to the present to ensure commitments were met.
This review will be complete by September 30, 1987.
9.
PROBLEM:
INADEQUATE RESPONSE TO ALARMS o
Refuel floor supervisor did not take corrective action in response to bridge alarm.
Shift Supervisor did not stop work after receipt of Area o
Radiation Monitor alarm.
6
O.
Violations: D, E
Short Term Corrective Action:
Procedures governing refuel floor work were revised to specifically address the proper action for an area radiation monitor alarm.
Result:
This procedural revision assured that workers were aware of the proper response to radiation monitor alarms on the refuel floor.
Long Term Corrective Action:
Training will revise materials to address response to area
)
radiation monitors by July 31, 1987.
l Radiation protection procedures have been revised to include general guidance to plant personnel as to the required action on receipt of unexpected area radiation monitor alarms.
This will be included in the plant staff training program by July 31, 1987.
The control Room annunciator response procedure has been revised to provide better guidance on when to stop work and evaluate the condition when an unanticipated ARM alarm is received.
10.
PROBLEM:
RADIATION TECHNICIAN WAS NEGLIGENT IN PERFORMING HIS DUTIES Technician was hosing off tool rather than performing o
proper survey.
Violation:
B Short Term Corrective Action:
l The radiological procedure for the refuel floor was revised to reaf firm that the radiation protection technician's primary responsibility is radiological surveillance.
The pre-job training sessions emphasized this item to the crews.
Result:
[
These actions have made radiation protection technicians more aware of their responsibilities.
Long Term Corrective Action:
Training materials for NYPA employees and contract radiation protection technicians will be revised to emphasize their independence from work.
This will be implemented by July 31, 1987.
7
A standing order has been developed for RES supervisor such that radiological sensitive jobs are monitored and verified for procedural compliance.
11.
PROBLEM:
INADEQUATE EQUIPMENT o
The cutting tool should not have been capable of capturing the piece of dry tube or a warning device should have been incorporated.
o Refuel Floor ARM alarms may not always get attention of personnel on floor.
Violation:
A Short Term Corrective Action:
Pre-job training sessions emphasized the shortcoming of the tool.
Result:
This action has reduced the likelihood of worker overexposure by making them aware of the' deficiencies of the tool.
Long Term Corrective Action:
The vendor was contacted and has stated that a design review of the tool will be, accomplished.
ARM alarms on the refuel floor will be modified to assure that personnel at any location on the floor will know they have alarmed.
This item will be completed prior to the next refueling outage.
12.
PROBLEM:
LACK OF SUPERVISORY OVERSIGHT o
No formal method existed to provide radiation protection supervisory oversight for work evolutions which present high radiological risks.
o Refuel floor supervisor was not properly supervising activities on the refueling floor.
Violations: A, B,
C Short Term Corrective Action:
Radiation protection supervisors were required to review and monitor work activities on this and other jobs deemed appropriate by the Radiological & Environmental Services Superintendent.
The refuel floor supervisors were required to attend pre-job training sessions that emphasized their controlling the work activity.
~
8
The authority and responsibilities of the refuel floor supervisor were clarified in written procedures.
Result:
These actions have increased the review and monitoring activities of supervisory personnel.
Long Term Corrective Action:
A Radiological and Environmental Services Department Standing Order was implemented March 4, 1987.
This procedure defines responsibilities and provides instructions for review of radiologically sensitive jobs and work areas.
The pre-job briefing check-of f list has been developed and includes a review of personnel authorities and responsi-bilities.
The procedure review check-off list addresses the adequacy of authority and responsibility delineation.
9