ML20043G613

Responds to Notice of Violation & Proposed Imposition of Civil Penalties in Amount of $75,000 Re Radiation Exposure. Corrective Actions:Worker Decontaminated & Examined by Physician.Civil Penalty Fee Transferred Electronically

ML20043G613
Person / Time
Site:	FitzPatrick
Issue date:	06/11/1990
From:	Fernandez W POWER AUTHORITY OF THE STATE OF NEW YORK (NEW YORK
To:	NRC OFFICE OF ENFORCEMENT (OE)
References
JAFP-90-0456, JAFP-90-456, NUDOCS 9006200489
Download: ML20043G613 (11)

Text

"; i 6 James A.MtsPetrick

< . 3 w 6 -s . Nuoteer Power Mont

.s. c. P.o. Box 41 .

[a4V. t Lycoming, Neo York 13093 :

315 342 3840 .

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"i. William Femandez 11

- Resident Manager 1

' June l11, 1990 m JAFP-90-0456 United States Nuclear Regulatory Commission Mail Station Pl-137

, Washington, DC 20555 Attention: Director, Office of Enforcement J

SUBJECT:

RESPONSE TO-NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY NRC INSPECTION NO. 50-333/90-12

REFERENCE:

a) USNRC letter dated May 10,-1990 on the same subject m EXPOSURES: 1) Response to Notice of Violation.

2) Long Term Corrective Actions Gentlemen:

The Authority agrees with the collective findings in the Notiet of Violations:and proposed imposition of civil penalties promulgated by reference (a).

Funds in'the amount of $75,000 for the assessed civil penalty have been transferred. electronically to the treasurer of the United States.

The Authority does request that the NRC review the decision basis for: the portion of the civil penalty above the base amount.

Reference (a) cited'several reasons why mitigation of the base penalty was not warranted.- As detailed in enclosure (1), several of these reasons are incorrect.

The NRC became involved with the investigative process very promptly after the incident. Accordingly, the NRC became aware of n ny of the issues in parallel with the Authority.

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Director, Office of Enforcement' '

_ June 11,,1990 U.S. Nuclear Regul'atoryECommission: .

'JAFP-90-0456 ,

Washington, DC 20555 Page ~2- ,

Discussions with NRC staff personnel prior to the enforcement conference focused onsthe desire to, discuss the generic. problems common to the March 8, 1990 event-and.the other non-routine radiologicalievents of the past several years. As a result =,.the broader issues of the event were stressed during the enforcement conference. The Authority believes.that it is inappropriate to use the information thus obtained as a basis for escalating or not mitigating the civil penalty above the base amount.

Very truly yours,

/V ,

WILLIAM FERNhNDEZ WP:ls J Enclosures ~

cc: R. Liseno 'NRC Resident Inspector G,-Vargo .

T. Martin, NRC Region 1 J.C. Brons (NYPA/WPO) NRC Document Control Desk R. Beedle (NYPA/WPO)- WPO Records Management J. Elmers' (NYPA/WPO) M. Knapp, NRC Region 1-DRSS Document Control Center -

CERTIFIED MAIL, RETURN RECEIPT REQUESTED j

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-U.S._ Nuclear Regulatory Commission- Page 1 of 9-Mail Station F1-l'37 Washington, DC 20555 a BNCLOSURE i NOTICE OF VIOLATION 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 1990, specifically on March 8, 1990, a Radiation and Environmental Services (RES) technician working in the Sample Sink area of the Radwaste Building, a restricted- area,  ;

received a total _ radiation exposure to the thumb of the left I hand of 48.8 rems while providing radiological coverage;for I a job involving the injection of sodium-24 (Na-24) into the reactor feedwater system during a feedwater flow test. The. L exposure on March 8, 1990 resulted in a cumulative extremity I exposure of the individual for the calendar quarter of 49.06 l rems.

B. Technical Specification 6.11 '(Radiation Protection Program) states that procedures for- personnel . radiation protection shall be: prepared and ' adhered to for all plant - operations. ,

These procedures-shall be formulated to maintain radiation- l exposures =. received during operation and maintenance as far

-below the._ limits specified'in 10 CFR 20 as practicable. The procedures shall address planning, preparation,.and training for operation and maintenance activities. They shall also

": include exposure allocation, radiation and contamination'and control techniques, and final debriefing.

1. Radiation Work Permit Procedure (RPP-4), Section 1.O, states, in part, that the purpose of the Radiation Work Permit (RWP) is to achieve good- radiation exposure control. Section 6.3.2 states that an RWP-is required-for jobs where special hazards are involved.

Contrary to the above, neither station approved work procedure - NWT-INSOL, Revision 0 (Preparation of Na-24 Injection _ Solution) nor Radiation Work-Permit (RWP).No.

90-0534-S~, both of which were established for a special hazards job involving the injection of Na-24 into'the reactor feedwater system of March 8, 1990, were adequate to maintain radiation exposure as far below the limits specified in 10 CFR Part 20 as practicable in that the work. procedure and the RWP did not achieve good radiological controls. Specifically, these documents did L not:

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- U.S.cNuclear Regulatory. Commission Page 2 of 9 -1 Mail-Station'P1-137-

- WashingtonF DC 20555 l~ a .' require any protective clothing for the Radiation l and Environmental . Services .(RES) technician

-(providing health physics job coverage) . entering and working in the Na-24 preparation and injection I area.;

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b. provide any requirements for performing personnel contamination monitoring at or near the Na-24 <

L preparation and injection area;

c. inform the workers that Na-24 was a beta radiation i emitting isotope necessitating a - beta radiation-survey of;the work area; and

d. provida any_ special- instructions or precautions cautioning against the direct handling of the Na-24:

capsule or capsule cap because of the potential for substantial levels of- high specific activity contamination remaining on the capsule or cap 'after -

'the removal of its contents, or as how to deal with a Na-24 leak at the preparation and injection area, #

should-one occur.

2. Station" a'pproved work procedure NWT-INSOL, . Revision 0-describes: the procedural' steps for opening the Na-24 shipping cask and preparing the injection solution. Step D;

', ;15'(a procedure step designed to minimize contamination)-

l requiresithat the Na-24 capsule cap be removed;by using e , the removal tool and tongs or tweezers, andithat the cap be'placed in a disposable container.  ;!

n Contrary to the above, on March 8, 1990, Step 15 of NWT-  !

L 'INSOL, Revision 0 was not adherod to in that: <

a. the NS-24 capsule cap was not placed in a disposable container after it removed from-the capsule'by the-vendor employees; and L,

b. the RES technician picked up the capsule cap with a glove on his right hand (rather than'a removal-tool, tongs or tweezers) and placed it back on the capsule.

These i violations have been categorized in the aggregate as a

-Severity Level III problem. (Supplement IV)

Civil Penalty - $75,000 (assessed equally among the violations).

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U.S. Nuclear-RegulatoryJCommission Page 3 of 9 Mail Station.P1-137 Washington, DC 20555 -

REPLY A. Violation of 10 CFR 20.101(a)

Admission or, Denial-of the Violation:

The~ Authority agrees with the violation of 10 CFR 20.101.

Reason for the violation:

T The violation occurred due to inadequate radiological controls cited in Part B of the Notice of Violation.

Corrective stens and results:

Corrective actions- for this event included decontamination of.

the-worker,. examination of the worker by a physician and a-detailed assessment of the.radiobiologically significant dose received by the worker.

The worker was' restricted from further occupational radiation exposure following'this event through the end of the calendar quarter endingLMarch 31, 1990. The worker was permitted to resume normal activities that involve or potentially involve' occupational radiation exposure with the beginning of the new calendar quarter.

Corrective stens that will' be taken to orevent further violation and-da$e when full comoliance will be achieved:

Enclosure 2 details the Authority's long-term corrective actions to this Notice of Violation.

B. 212Jation of TechniqAl Soecification 6.11' Admission or denial of the Violation:

The Authority agrees with the violation.

Reason for the violation:

The violation cited in B.1 resulted from weaknesses in-the radiation _ work permit (RWP). procedure,. the ALARA review process and training. The violation cited in B. 2 resulted from inadequate review of work procedures.

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• _U.S.-Nuclear Regulatory Commission Page 4 of 9 Mail Station Pl-137

-Washington,.DC- 20555 Corrective stens and results:

Corrective actions taken prior to the second performance of the sodium-24'(Na-24) feedwater flow test included upgrading of- the radiological controls and protective clothing requirements-for the work activity and specific training of

-workers in the unique circumstances of the task. In addition, a review of the adequacy of the radiological controls was performed by an independent radiation specialist.

The Resident Manager reviewed this incident and the implications to maintenance, construction and radiological supervisors and foremen. Especially stressed was the inappropriate reduction of protective radiological controls for personal' convenience. In a similar fashion,-department.

supervision counseled the radiological protection staff in the need to maintain a conservative and questioning attitude when dealing with non-routine radiologically sensitive. work.

The event was independently evaluated by INPO using their Human Performance Enhancement System (HPES). The review identified weaknesses in procedures (including not using a disposable contain'er) , training . and ' supervision similar to those identified in Inspection Report 90-12 and the Authority's own assessment.

Third-party' review of radiological work requiring an i ALARA review are being performed by an: independent Certified Health Physicist. Management observations of radiological work practices and the adoquacy of radiation work permits have been-increased and the Authority has contracted outside radiological protection specialists to assist in job reviews end observations of radiological protection technician 1

performance and worker practices. These reviews of radiologically _ sensitive work will continue until the long-term ALARA Procedural actions described in Enclosure 1 (paragraph 2A) are implemented.

Corrective steos- that will be taken to avoid further violation:

Refer to 2nclosure 2 which contains the Authority's long-term ec/rrective actions to this Notice of Violation.

DJlLtJLwhen 'f ttFL comoliance will be achieved:

Retor to Enclosure 2 for the specific implementation schedule of corrective actions and programmatic upgrades.

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= U.S.; Nuclear' Regulatory Commission Page 5 of 9 Mail Station F1-137 Washington, DC 20555 C. Other Comments:.

After reviewing the t'cansmittal letter of May 10, 1990, the Authority has identified several statements which we believe are in error or require further: clarification:

One paragraph states "Although you promptly reported this-incident to the ERC,' ybu did not identify.several significant

, contributing de 'iciencies in; the planning and preparation for this evolution ... Specifically you did' not identify that inadequate protective clothing l requirements in_ the -RWP contributed!toithe contamination,' noridid you' identify lthat a contamination control stepfin work procedure had not:been

-followed."- This statement is incorrect. At the time the incident was reported to _ the NRC, the investigation was ongoing and incomplete. The reports to the NRC were.made as soon as practical following discovery of the potential significance of the-event. During the enforcement conference, as documented in your meeting report for Inspection 90-12, inadequate- a'ssessment of risk, reductions in' protective clothing requirements and weak procedures were addressed (Tab 1.2 of the Authority's presentation). In addition, the Authority stated' that an- independent human -performance in cstigation.was to.be performed by INPO. Their report was finalized and1 transmitted to the Authority on April 26, 1990.

The same paragraph also states that " . . .- your long term

-corrective actions, as.Let forth-in your presentation at the enforcement conference, .were not considered comprehensive, in that weaknesses in the radiation work permit procedure and technician training to improve awareness of risks associated with infrequent job tasks were not addressed." The Authority disagrees with this assessment. CorrectiveL actions relative to the-radiation work permit program and technician training were addressed during the enforcement- conference, as documented in-your meeting report for Inspection 90-12 (Tab 4.4.B 1 and' 2 of the Authority 8 s presentation) .

While the-specific details of these corrective actions were not presented at the time of the enforcement conference, the Authority clearly recognized the need for improvements in these areno. Specific details were not presented because they had not yet been formalized. Detailed plans and procedures could not be developed due to the relative short time interval More time between the event and the enforcement conference.

was necessary to ensure that long-term corrective actions were sufficiently comprehensive to address the deficiencies identified in this event in addition to other recent events as discussed with the NRC staff. Due to the complex nature

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.(U.SL Nuclear Regulatory Commission-Page 6 of 9

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, f a 1 u _of some of the issues identified in our analysis of this and ,

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other recent events, it was inappropriate to propose specific

_ corrective' actions that might not have been comprehensive.

1{ In pre-conference discussions, NRC' staff members stressed the n -importance of addressing the root causes of the March 8, 1990

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event as related- to: other similar non-routine events- at i g FitzPatrick. The Authority' agreed and consequently avoided' P addressing this most recent event as an isolated incident. .

o Special emphasis was.given_to the broader implications of-the

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A March 8, 1990 overexposure.

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l- The-Authority undertook a considerable effort to accurately

,' 'y assess the actual dose receivrid by the worker from the March L 8,1990 contamination event. This assessment involved outside' j b '

consultants' including' a recognized exrert in radiation l

, dosimetry and a licensed physician. On the basis of these assessments, we believe that the actual 6ose received by the.

worker was 17.39 rems as opposed.to the 49.06 rems cited.

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A considerable body of scientific evidance published by the P ,

International Commission on Radiological Protection (ICRP ,

Ew J , Report 23) and others, indicates that the critical tissue in 1 the case of the extr% ties (the basal layer of the epidermis) g is. _ at a depth ; co'. iderably greater than the present- NRC .;

Regulatory Guidancu ;f 7' mg/cm' . In this particular case the 1 0 .

depth of _ this layer is' on the order of 64- mg/cm' . The use of-n m the 49.06crem dose assessment is, we believe, given the circumstances;of'the exposure and misrinappropriate epresents the

i m radiobiological. significance-of the contamination event, g< 1 I

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R U.S. Nuclear Regulatory Commission Page 7 of 9 Mail Station P1-137 Washington, DC 20555 ENCLOSURE 2 Long-Term corrective and Preventive Actions to Improve Management control and oversight of Non-Routine Radiologically Significant Activities

1. Organisation and Personnel Responsibility Improvements Management controls on non-routine radiologically significant activities will be strengthened through the procedures and programs described below. These improvements include progressively higher management approvals proportional to increased radiological risk, especially for first-time or infrequently performed tasks.

As a result of the several radiological events over the past few years, the Authority recognizes that organization and personnel responsibilities and accountabilities need to be clarified, improved and/or changed to ensure that they are not fragmented or diluted. To address these needs, a staffing study and organizational review has been initiated with completion scheduled by the end of 1990. In addition, the expectations and responsibilities required of all personnel to produce a high level of professionalism will be better defined and promulgated by the end of 1990.

2. Procedures and Programs A. ALARA Review The existing ALARA Review process will be enhanced significantly. The present procedure is used for various types of ALARA Reviews including design activities, operations, modifications, maintenance and special evolutions such as the sodium-24 feedwater flow test.

Presently, the procedure only requires escalated management approval on the basis of collective dose (i.e.

man-rem) and does not address overall radiological risks (e.g. high dose rates, high airborne or contamination potential.)

The ALARA process and procedure is to be enhanced to require expanded radiological assessments for specific types of work (e.g. spent fuel pool work) as well as for those conditions when actual or anticipated radiological conditions are above some trigger level.

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U~S. Nu$ lear: Regulatory Commission

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n.? Washington,LDC'"205S5 The radiological assessments will include a review:of.the plant operating' experience data base, en evaluation of-

- credible abnormal or accident scenarios 1knd' contingency plans' for - such scenarios. - The procedures - will also require progressively higher levels of management approval based on overall radiological risk, rather than the current requirement for such approvals that is based v strictly on: collective dose.

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This' effort will be complated by September 30, 1990.'

B. -Radiation Work Permit s As aJresult of management assessuents previous toithis event, the Authority had already decided to undertakeEa4 major upgrade-of the FitzPatrick-radiation work permit (RWP) program. The= primary purpose of this upgrade.is to enhance the effectiveness of the RWP procedures while

. reducing the unnecessary administrative burdenJimposed

bythe existing system. One expected benefit of this-upgrade-is-to' allow additional 4 technician resources to be focused ~on,in-plant observation and job' coverage..

=ThisJ upgrade will provide clearer; guidance on minimum

acceptable protective requirements-and; instructions for.

RWP j ob' coverage' and ~ require progressive: management approval. for variances from -normal , protective-requirements. :The = procedure will also (formalize when -

supervisory - ' approval 'is . required prior) to work commencements.

The Authority expects ' implementation of the upgraded RWP 1 program by December 31, 1990, 1

~ C. Procedures for Radiological Work-Activities The' structure and quality of vendor procedures for the performance of the sodium-24 feedwater flow test was less

> than adequate because the procedures ' were : not in'the , ,!

Authority's normal format. In addition, radiological .L controls.were not integrated into the vendors procedure which was considered to be the governing document for the test procedure.

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q. The radiological assessment process' defined in 2A above, W' will. include guidelines and thresholds above which g- . radiological controls need to be fully integrated into non-routine significant radiological work procedures,.

rather than relying on a general reference to radiological requirements.

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.U!S.1 Nuclear > Regulatory Commission .Page 9 of 9 MailtStation P1-137, a

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3. Training.

. ,T A. Technician Training

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H As a result of the non-routine radiological events,over i the past- few years, the need to upgrade the qualification and training . (especiallyc continuing 1 training) programs for radiological technicians has'become quite evident.

p M Y The .present' union job.. description / trdining and:

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qualification 1 program .is definedt ~for- 'ni~ combined j

. radiological / chemistry technicien. This program has , H resulted.'in a dilution'of the, specific skills) required s M for - radiological . technicians. . Changes inlthe ioverall 1 1 program, are -beingl pursued to L, increase .the._overall j effectiveness. These changes include.

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Higher qualification standards to become- a; technician. tj q

- A redefined qual'ification/ apprentice program. in j

& which an individual would specialize in radiation protection or chemistry.

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. training program ,which will( support: the C (4; '

specialization of technicians.-

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These changes are subject to union negotiation and; as. a result, an' exact date for completion can not beJset. 7' Nevertthe less, this overall upgrade should-be in effect by December.of 1990.-

.c .B. t Supervisory Training

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The procedures for, management. control and-oversight of 4 m radiologically significant activities:are contained in. , s W

different plant procedures. Specific training 1for the i

,. radiological' . protection management staff will be iY Y, conducted to review the requirements of each .of these l

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procedures. 'In additiori, training- in observation

,m itechniques has. been or w

. ill 'be completed. for' the radiological protection management staff.

First-line radiological protection supervisors will ,

1 attend applicable portions;of the upgraded continuing  !

M 'W training program' for radiological protection technicians.

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