ML20206P121

Insp Rept 50-213/86-22 on 860722-25.Violation Noted:Failure to Adequately Control Work in High Radiation Areas During Steam Generator Maint Activities,Which Led to Whole Body Occupational Exposure in Excess of Federal Limits

ML20206P121
Person / Time
Site:	Haddam Neck File:Connecticut Yankee Atomic Power Co icon.png
Issue date:	08/15/1986
From:	Lequia D, Shanbaky M, Weadock T NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:
Shared Package
ML20206P113	List: ML20206P108 ML20206P121
References
50-213-86-22, NUDOCS 8608270102
Download: ML20206P121 (11)

See also: IR 05000213/1986022

Text

_ _ _ _ _ _ _ _ _ ___ - _ _ -

-

.

U.S. NUCLEAR REGULATORY COMMISSION

Region I

Report No. _86-22

Docket No. 50-213 _

License No. OPR-61 Priority --

Category C

Licensee: Connecticut Yankee Atomic Power Company

i

Post Office Box 270

Hartford, Connecticut 06101

Facility Name: Haddam Neck Nuclear Power Plant

Inspection At: Haddam Neck, Connecticut

Inspection Conducted: July 22-25, 1986

Inspectors: 4/t 8-If-80

. Weadock, pation/S ecialist date

D. LeQuia, (griatioVSiec'alist

& 8 -tS- 8 to

date

/

Approved By: -9V/ N hd/b/

M. ShanbakF, ~ Chief, Facilities Radiation

_ g////f'[

date

Protection Section

Inspection Summary:

Areas Inspected: Routine unannounced inspection of the Radiation Protection

Program during steam generator eddy current testing and tube plugging evolutions,

including: ALARA, High Radiation Area Control and Radiation Protection Program

implementation.

Results: Within the scope of this inspection, three violations were identified

pertaining to a failure to adequately control work in high radiation areas dur-

ing steam generator maintenance activities (see discussion in Section 3.0).

This failure of control led to a whole body occupational exposure in excess of

federal regulatory limits.

8600270102 e60819 '

PDR ADOCK 05000213

G PDR

,

_ , , , _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . - , . - - - - __

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

. .

.

DETAILS

1.0 Persons Contacted

During the course of this inspection, the following personnel were con-

tacted or interviewed:

1.1 Licensee Personnel

J. Ferguson, Unit Superintendent

• G. Bouchard, Station Services Superintendent

• J. LaPlatney, Assistant to Station Superintendent

• J. Ashburner, Supervisor - Betterment and Construction

H. Clow, Health Physics Supervisor

• W. Nevelos, Radiation Protection Supervisor

• R. Brown, Operations Supervisor

• W. Bartron, Maintenance Supervisor

1.2 NRC Personnel

• S. Pindale, Resident Inspector

• M. Shanbaky, Chief, Facilities Radiation Protection Section.

Other licensee or contractor personnel were also contacted or inter-

viewed during this inspection.

• Attended exit meeting on July 25, 1986.

2.0 Purpose

.

The purpose of this inspection was to review and evaluate the licensee's

radiation protection activities during a mini-outage for steam generator

eddy current testing and tube plugging operations. This evaluation, which

started as a reutine inspection, became reactive in nature following the

identification of an occupational radiation exposure of one worker in excess

of the regulatory limits of 10 CFR 20.101(b). The following elements are

included in the evaluation:

• Radiation Protection I'mplementation/0verexposure Incident

• . AuM ,

• High Radiation Area Controls

.

O

'

.

.

3

,

.

3.0 Overexposure Incident

On July 23, 1986, the licensee communicated to NRC representatives on-site

that an apparent whole body radiation exposure to one worker in excess of

federal limits had occurred during steam generator (S/G) work activities.

The involved worker (Worker A) was performing work to support hyorostatic

testing of S/G #4 from approximately 3:00 am to 5:30 am on July 23, 1986.

Worker A's activities included the performance of multiple " half-Jumps"

(insertion of the head, arms and chest) into S/G #4 for camera reposition-

ing. The apparent overexposure was discovered when the worker's pocket

ionization chamber (PIC) was read after the completion of work activities.

Worker A's high range PIC, positioned on the head during work, indicated

an exposure of 1700 millirems. This exposure, when added to the worker's

previous exposure for the quarter (1620 millirem), indicated an exposure

(3320 millirem) in excess of allowable limits (3000 millfrem/ quarter).

The licensee immediately processed worker A's TLD badge, also positioned

on the workers head, to determine the dose received. The TLD badge is the

licensee's official dosimeter for records. The badge indicated an exposure

of 1672 millirem, which, when added to the previous quarterly exposure,

indicated an exposure in excess of regulatory limits (3292 millirem).

NRC investigation into the events leading to the overexposure included the

following activities:

--

D.iscussion with involved personnel.

--

Discussion with Health Physics supervisory personnel.

--

Tours and observation of ongoing work activities at the S/G worksite.

--

Review of the following documentation:

• S/G worker " jump sheets" and exposure records.

. ,

Procedure ACP 1.0-4, " Radiation Work Permit Completion and Flow

Control".

• Training and qualification records for involved personnel.

Based on the above review, three apparent violations were identified. A

description of the events leading to the overexposure is given below.

3.1 Event Description

Steam generator work activities on July 23, 1986 included. tube marking

in S/G #2 and hydrostatic testing of S/G #4. HealthPhysics(HP)

staffing to support work activities included two senior HP technicians

and an HP clerk. One senior technician was stationed at the control

,

e

.

- _. . - - - . . _ = . _ _ - - - . - - --- .. . __

. --- --

.

4

.

t

,

4

i

!

'

l

'

point desk outside the loop bioshield area. This individual's respon-

sibilities included monitoring S/G work via closed circuit TV, time-

l keeping for S/G workers to track and control expohure, and maintaining

communications via headsets with the S/G workers. The second senior

HP technician and the HP clerk were available to control the dressing

I and undressing of S/G workers, and to periodically read the workers

l

PIC to monitor his exposure.

! Workers performing S/G maintenance requiring insertion of their body l

1 into the S/G channel head were required by the controlling RWPs to

i wear the following dosimetry: thermoluminescent dosimeters (TLDs)

on the chest, hesd, and hands. Along with each TLD, a worker wore a

l pocket ianization chamber (PIC), which provides on the spot estimates  ;

.

of exposure.. Workers performing jump activities wore plastic suits

l and bubble hoods for respiratory protection purposes. Since the bubble  ;

hood prevented easy access to the PIC on the workers head, the tech-

'

i

'

nicians placed " sacrificial" PICS on the outside of the hoods to allow

i easy reading. This " sacrificial" PIC was not required by the RWP.

horker A began work on S/G #4 at approximately 0300. He had already

i

received 1620 millf rem of exposure during this quarter and was conse-

] quently authorized to receive an additional 880 millirem before the

station administrative quarterly limit of 2500 millirem was reached.

!

He performed two half-jumps into the channel head (20,000-30,000 mR/hr)

{ and continued working on the S/G platform (250-1000 mR/hr) until

approximately 0450, at which tirre he.was called out of the area by

l the HP technician to have his PIC read. At this point, it was noted '

that the " sacrificial" PIC located outside the bubble hood was missing.

j The two senior HP technicians conferred and agreed to allow worker A

! to return to the S/G platform and resume work activities. The senior

! technicians evaluation which lead to this decision was based on the ,

technicians knowledge of previous work activity: earlier that shift,  ;

Jl a worker had performed what was thought to be similar work on S/G #4 *

.

and only received 850 millirem in three and one quarter hours.

J

sWorker A returned to work and completed his work activities by approx-

! Imately 0530. During this period, he made two additional half-jumps

'

into the S/G. Upon removal of his bubble hood, the two PICS on his ,

head (one low range 0-1500, one high range 0-5000) were read. The low

range PIC was found to be offscale; the high range PIC showed an

,

exposure of 1700 millirem. At this point, station personnel recognized

an apparent overexposure had occurred and worker A's TL0s were sent

, for processing. Results from the whole body TLD located on worker

A's head showed 1672 millirem, which, when added to exposure received

previously in the quarter, gives a total quarterly exposure of 3292

.

millirem.

l

'

l

4

!

.

+

._. _ _ __ _ _ _ _ _ _.. _ __ _ _. __ . _ . ._

,

~

'

!' 5

j

I -

!

,

10 CFR 20.101(b)(1) requires that "during any calendar quarter, the

j total occupational dose to the whole body shall not exceed 3 rems".

l Failure to restrict worker A's quarterly exposure to less than 3 rem

(3000 millirem) is an apparent violation of 10 CFR 20.101(b)(1).

l (213/86-22-01)

!

'

3.2 Causal Factors

t

l Subsequent NRC review of the above events identified the following

j apparent direct causes of the overexposure.

4

'

1. The Hp technicians failed to appropriately monitor and control

worker A's exposure during the work activity. Procedure ACP

1.0-4, " Radiation Work Permit Completion and Flow' Control," Step  ;

i 5.6.1.6, requires, in part, that "... direct surveillance of '

j workers by a Health Physics technician will be required in those

instances where high dose rates, extreme changes in radiation f

levels, or other radiological hazards preclude workers from

independently monitoring and minimizing their exposure."

l

j Failure.of the HP technicians to read worker A's Plc during the

i S/G work activity constitutes an apparent violation of Procedure

! ACP 1.0-4. (213/86-22-02).

i

The inspector determined from: (1) worker A's stay times in the

l high radiation areas, and (2) licensee dose rate measurements,

I

'

that worker A's exposure at 0430 was approximately 700-800 mrem.

This additional exposure would have brought him near his admin-

l

1strative quarterly whole body limit of 2500 mrem.

$ 2. The HD technician's decision to allow worker A to return to work

} based on another worker's (worker 8) stay time and exposure was

i unreasonable since a subsequent interview of worker B indicated

! that: 1) he had not made any whole body entries to the S/G, and

j 11) had retreated to a lower dose area off the S/G platform when- ,

ever he was not required to be there. 10 CFR 20.201(a) defines

-

,

a " survey" as an evaluation of the radiatton hazards -incident to

] the production, use, release, disposal or presence of radioactive

j materials. 10 CFR 20.201(b) requires that each licensee make

such surveys as necessary to comply with all sections of Part

j

.

20.

L

! The use of an inappropriate evaluation of radiation hazards and

l radiological conditions in extending the workers stay time con- '

1 stitutes an apparent violation of 10 CFR 20.201(b) in that an

l adequate survey (evaluation) was not performed. (213/86-22-03)

-

l

!

[ ,

,

l

.

$

.

.

6

3.3 Contributing Factors

NRC investigation of the above incident also identified several

problems with the radiological control of the S/G work activity.

Al+. hough these problems do not appear to be directly related to the

overexposure, they may be contributing factors and are deserving of

note and specific attention by tFe licensee.

1. Worker A was originally directed to perform tube marking activ-

ities on S/G #2; he consequently initialled and checked into

containment on RWP #864038 for S/G #2. Once inside containment,

worker A was directed by Westingh6use super /ision to support the

hydrostatic testing of S/G #4; no change to the RWP sign-in sheets

was made and worker A did not initial RWP #864040 "S/G #4 Tube

Plugging Project" to indicate he had read it. Procedure ACP

1.0-4, " Radiation Work Permit Completion and Flow Control", Step

5.5.2, requires in part that ".. . workers are responsible for

initialling the RWP ... acknowledging they have read and under-

stand the RWP...". Failure of worker A to initial the sign-in

sheet for RWP #864040, which he subsequently worked, constitutes

an apparent violation of ACP 1.0-4,(213/86-22-02). The inspec-

tor compared the two RWPs and determined that reauired radiolog-

ical controls were identical. Questioning of worker A indicated

that he had been appropriately briefed as to the dose rates ard

conditions for S/G #4, rather than S/G #2. The above failure to

sign-in on the correct RWP therefore did not act as a causal

factor for the subsequent ovarexposure.

2. Interviews of other workers performing S/G work indicated that,

even when available, PICS were not always read by the HP tech-

nicians. One worker indicated his PIC was not read once during

a three-hour work period on a S/G platform.

3. Several workers indicated that the cable bookups to the headphones

worn by the workers were too short and may have restricted their

ability to move to a lower dose rate area.

3.4 Licensee Corrective Actions

1

On the afternoon of July 23, 1986, the licensee interviewed the indi-

viduals involved in the overexposure incident, including: Health

Physics, supervisory and worker personnel. From these interviews,

they concluded that a failure to comply with company procedures and

policies did exist in relationship to the overexposure of one of the ,

steam generator workers. Based on their findings, the licensee allowed

work to recommence with the following additional controls implemented

to prevent reoccurrence: ,

,

l'

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

.

.

7

1. The licensee reemphasized that job supervision and the HP Tech-

nicians assigned S/G responsibilities will have a prejob discuss-

ion including upcoming job scope and goals to be achieved prior

to entering containment.

2. Platform workers will be issued a Dositec with an alarm setpoint

200 mR below the available quarterly licensee's administrative

limit. These workers will-be instructed to exit the loops area

if the alarm setpoint is reached and report to the S/G control

point. If the worker leaves the skirt prior to the alarm, a HP

technician will monitor the PIC reading prior to allowing the

worker back onto the platform.

3. While in the S/G skirt, workers will be instructed to minimize

time spent on the upper platform in the area of the manways.

4. When multiple entries are required to the upper platform or

channel head, the waiting between entries will be done in lower

dose rate areas outside the skirt. Back-up jumpers will wait in

the bullpen, not in the skirt.

5. Any questiorable PIC readings will terminate all activities

associated with the affected S/G until HP supervision has

reviewed the situation.

o.

6. A dedicated HP work group will be supplied for each S/G.

7. High Radiation Authorization Cards will be issued for one RWP.

Entry on subsequent PWPs will require additional High Radiation

Authorization Cards.

During subsequent tours of the containment butiding and steam generator

work area, the inspectors observed that these additional steps appeared

to provide sufficient control for the work in progress.

4.0 ALARA

The licensee's program for maintaining and ensuring that doses to workers

remain "As low As Is Reasonably Achievable" (ALARA) was reviewed against

criteria in:

• 10 CFR 20.1, " Purpose"

Regulatory Guide 8.8, "Information Relevant to Ensuring that Occupa-

tional' Radiation Exposures at Nuclear Power Stations Will Be As Low

As Is Reasonably Achievable"

Regulatory Guide 8.10 " Operating Philosophy for Maintaining Occupa-

tional Radiation Exposures As Low As Is Reasonably Achievable"

.

.

8

The licensee's performance relative to the above criteria was determined

by:

Review of the steam generator primary side tube plugging job exposure

summary.

Interview with the ALARA Coordinator.

• Review of personnel exposure records.

Review of radiation survey results performed in support of steam

generator repair activities.

Review of the Plant Design Change Request (PDCR #839) and its accom-

panying Design ALARA checklist for steam generator tube plugging.

Review of 1986 station exposure goals vs. current exposure status.

Within the scope of this review, no violations were identified. However,

some strengths and significant weaknesses in the ALARA program were noted.

' hey are discussed in the following text.

.

The licensee is continuing in their efforts to improve the ALARA program.

Conseqtently, a significant monetary incentive increase was recently

proposed and accepted raising the dollars / man-rem from $1000/ man-rem to

$20,000/ man-rem. This substantial increase, one of the highest in the

' industry, should help to justify the capital costs associated with procure-

ment of the equipment and/or processes necessary to reduce dose rates,

and, thereby, bring a turnaround in the escalating exposure at the plant.

Review of the current 1986 exoosure status identified that over 1616 man-

rem have beep expended thus far, with an additional 135 man-rem budgeted

for the steam generator mini-outage. This will bring station exposure to

approximately 1750 man-rem for the year; well above the man-rem exposure

associated with a typical pressurized water reactor.

It appears, however, that the licensee's good intent in the ALARA area is

weakened at the point of implementation.~ This is evidenced by their ,

staging of workers on the steam generator (S/G) manway platforms or skirt

areas, which are high radiation areas, for extended periods of time during

S/G maintenance activities. In addition, low dose rate working areas for -

this activity were not effectively established. These poor practices may

have contributed to an exposure of a worker in excess of federal limits as

discussed in Section 3.0 of this report.

Further investigation of the ALARA program identified a continuing tendency

to submit Plant Design Change Requests (PDCR) to the ALARA group with

insufficient time to orovide effective exposure reduction input for the

job. During discussions with the ALARA Coordinator, he stated that PDCR

.

,

.

.

9 -

1. 839, which concerned S/G. tube plugging, was not submitted for review until

July 19,1985, with work commencing on July 20, 1986. He stated that this

'

was an insufficient amount of time for a proper review. Additional dis-

cussions with the ALARA Coordinator appeared to indicate a lack of ALARA

group involvement and oversight of on going work activity to ensure that

all ALARA provisions have been complied with, or if additional measures

are necessary. This lack of oversight may have contributed to the over-

exposure incident, as workers stated that they felt that the communication

lines for S/G work were too short to allow them to move to low dose rate

areas. -

5.0 High Radiation Area Control

The licensee's program for the control of high radiation areas was reviewed

against criteria contained in:

• 10 CFR 20, Standards for Protection Against Radiation.

Technical Specification 6.13, "High Radiation Area".

The licensee's performance relative to the above requirements was determined

by:

• Review of High Radiation Area Authorization Cards.

Review of Radiation Work Permits for work in support of steam generator

n.ai ntenance.

• Review of survey records.

Independent surveys performed by the inspector.

Tours of the reactor containment building.

Observation of health physics procedure implementation and utilization

at the work site.

• Inspection of locked high radiation areas in the reactor containment

building.

Review of Radiation Protection Procedure 6.2-8, " External Radiation

Exposure Control and Dosimetry Issue".

.

Review of Administrhtive Procedure 1.1-92, "High Radiation A.rea Key

Issue".

Review of Radiation Protection Procedure 6.1-7, " Posting of Radio-

logical Control Areas".

, ,

. ,

k

-

.

.

10

.

Within the scope of this review, no violations were noted. However, two

apparent weaknesses were observed, concerning: (1) control of tne locked

high radiation area that provided access to #2 and #3 steam generator; and

(2) monitoring requirements for entry to high radiation areas. These items

are discussed below.

5.1 On July 23, 1986, while making a tour of the containment building,

the inspector observed a locked high radiation area (LHRA) gate propped

open. This gate allows access to the loop areas of the plant. A

health physics (HP) technician was observed sitting just outside this

gate. The inmector asked the technician if he could enter the area

as part of his tour. The technician stated he was not assigned as a

gate watch. (Radiological Protection Procedure RAP 6.1-7, specifically

requires that areas with '... dose rates greater than 1000 mrem / hour

shall have all entrances locked or shall be continuously guarded to

prevent unauthorized entry..."). The inspe.: tor proceeded to the lower

containment HP checkpoi.nt to verify entry and control requirements.

After being assured by checkpoint personnel that the HP technician

was indeed stationed to guard the gate, and that entry to the area as

equipped was possible, the inspector returned to the gate and entered

the area. While in the LHRA, the inspector observed the HP technician

leave the gate area and proceed into the loop areas to assist a S/G

worker out of his plastic suit. This effectively left the gate un-

guarded. During subsequent discussions with licensee personnel at

the checkpoint, they stated that the gate is observed on a television

monitor when it is left unattended. However, the inspector noted

that the individual placed to observe the bank of four monitor screens

would have difficulty in providing positive control of each entry to

this LHRA, because the individual indicated that his prima responsi-

bilities were timekeeping and control of S/G channel head entries.

These responsibilities required constant attention and appeared to

preclude effective control of the monitor for the gate area. This

issue was discussed with licensee management, who suspended contain-

ment work activities at noon on July 23, 1986, to investigate this

incident, the overexposure incident (see Section 3.0) and high radia-

tion area entry concerns raised by the inspector. After recommencing

work in containment, the inspector again toured the area and noted

that effective health physics controls had been established to control

access to locked high radiation' areas.

~

5.2 During entries into the containnient, and subsequent tours of the S/G

maintenance area, the inspector observed personnel entry into 00sted

high radiation areas. Technical Specifications require that an indi-

vidual or group of individuals permitted to enter such areas shall

be provided with one or more of the following:

!*

.

11

1. Use of a continuously indicating dose rate instruent;

2. Use of an integrating dose device which alarms at a preset value;

or,

3. Use of an individual establishing positive controls and equipped

with a dose rate dev' ice who performs periodic radiation surveil-

lance at the frequency specified in the RWP.

The inspector observed personnel entering containment and one steam

generator worker exiting the loop areas, both of which are posted and

controlled as high radiation areas (HRA), without the use of a dose

rate' instrument or integrating dose device (options ~one er two).

During subsequent discussions with the licensee, they indicated that

option three was being exercised. An apparent weakness exists when

the licensee uses option three. In tr.is situation, workers are sent

into posted HRAs equipped only with a thermoluminescent dostmeter and

a pocket ion chamber (PIC) and not accompanied by, or positively con-

trolled by, a person qualified in HP, who performs periodic radiation

surveillance. The licensee was relying on routine surveys rather

than pe-iodic radiation surveillance at a frequency specified in a

Radiation Work Permit (RWP). The Technical Specification requirement

for periodic s~urveys is further defined ~by the licensee in Procedure

ACP 1.0-4, as'" intermittent". The term periodic, as it applies to

radiation surveillance, needs to be clearly understood by the HP

technician covering the job; either by verbal briefings, procedural

direction or RWP requirement. In addition, the frequency of periodic

surveillance must be consistent with_the radiological hazards asso-

ciated with the activity. The licensee's practice of allowing per-

sonnel to enter posted HRAs under option three without accompaniment

by a health physics qualified individual equipped with a dose rate

monitoring device, does not meet the requirements of Technical Spec-

i fication 6.13.1.C. However, a violation will not be issued at this

time, since licensee surveys, and independent surveys performed by

the inspector, verified that the individuals had not entered any high

radiation fields above 100 mrem /hr. The Technical Specification

requirement to provide periodic radiation surveillance was discussed

with licensee management, who stated that access to, surveillance and

control of work activities in High Radiation Areas will be examined

and upgraded as necessary'. The inspector stated that this area will

be reexamined during a future inspection ~

6.0 Exit Meeting

The inspectors met with licensee management denoted in Section 1.0 on

July 25, 1986 at the conclusion of the inspection. The scope and findings

of the inspection were discussed at that time.

-

-