ML20207K163

Insp Repts 50-369/86-15 & 50-370/86-15 on 860603-05. Violation Noted:Failure to Follow Radiological Protection Procedures

ML20207K163
Person / Time
Site:	McGuire, Mcguire
Issue date:	07/15/1986
From:	Hosey C, Revsin B NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
To:
Shared Package
ML20207K116	List: ML20207K112 ML20207K143 ML20207K163
References
50-369-86-15, 50-370-86-15, NUDOCS 8607290350
Download: ML20207K163 (9)

See also: IR 05000369/1986015

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UNITED STATES

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NUCLEAR REGULATORY COMMISSION

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101 MARIETTA STREET, N.W.

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ATL ANTA, GEORGI A 30323

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Report Nos.:

50-369/86-15 and 50-370/86-15

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Licensee: Duke Power Company

422 South Church Street

Charlotte, NC 28242

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Docket Nos.:

50-369 and 50-370

License Nos.:

NPF-9 and NPF-17

Facility Name: McGuire

Inspection Conductec :

June 3-5, 1986

Inspectors:

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Date Signed

Approved by:

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C. M. Hos6 # Section) Chief

Dat'e Signed

Division of Radiatiorl Safety and Safeguards

SUMMARY

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Scope:

This special unannounced. inspection involved onsite inspection during

normal duty hours in the area of external exposure control.

Results: One violation - failure to follow radiological protection procedures.

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8607290350 860716

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1.

Persons Contacted

• B. Hamilton, Superintendent, Technical Services

• J. Foster, Station Health Physicist

• W. Byrum, Health Physics Coordinator

• L. Lewis, System Health Physicist

• N. G. Atherton, Compliance

P. Huntley, Health Physics Coordinator

J. Carroll, Health Physics Supervisor

Other licensee employees contacted included six technicians, two mechanics,

and four office personnel.

Other Organizations

Radiological Services

Numanco

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NRC Senior Resident Inspector

• W. T. Orders

• Attended exit interview

2.

Exit Interview

The inspection scope and findings were summarized on June 5,1986, with

those persons indicated in Paragraph 1 above.

One apparent violation for

failure to follow radiological protection procedures was discussed in

detail.

The licensee acknowledged the inspection findings and took no

"

exceptions.

The licensee did not identify as proprietary any of the materials provided

to or reviewed by the inspector during this inspection.

3.

Inspector Followup of Onsite Events (93702)

a.

Synopsis of Event

On the morning of Ma, 29, 1986, a contract health physics technician,

who had been performing work in Unit I lower containment, was found to

be contaminated upon exit from the Reactor Building (RB).

The

contamination was identified as a single microscopic particle of-mixed

nuclide composition with a total activity of 0.802 microcuries.

The

technician was decontaminated by showering and a dose to the skin of

the whole body of 4525 millirem was assigned to the worker.

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b.

Review of Exposure Event

Through discussions with licensee representatives, interviews with

involved personnel and review of licensee records, ~the circumstances

surrounding the May 29, 1986, contamination event were examined. On

that date at approximately 0415 hours0.0048 days <br />0.115 hours <br />6.861772e-4 weeks <br />1.579075e-4 months <br />, a vendor health physics (HP)

technician dress'ed out in one pair of cloth coveralls, one pair of

cotton . glove liners, two pair of rubber gloves, two pair of plastic

booties, one pair of rubber overshoes, a particulate respirator, and

two hoods and at 0445 hours0.00515 days <br />0.124 hours <br />7.357804e-4 weeks <br />1.693225e-4 months <br /> entered into Unit 1 lower containment. The

technician was to provide general support for the steam generator, (S/G)

"D" platform crew who were involved in nozzle dam installatfor. work. A

platform had been erected at the S/G "D" manways in upper cotitainment

and entry to the platform was via a ladder, the bottom of which rested

in lower containment. The area surrounding the foot of the ladder had

been roped off as a radiation control zone (RCZ), the floor of which

had been covered with Herculite.

The Herculite had been extended to

form walls about the RCZ of approximately two to three feet in height.

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Between 0445 and 0530 hours0.00613 days <br />0.147 hours <br />8.763227e-4 weeks <br />2.01665e-4 months <br />, another HP technician was assigned to

containment. to perform such activities as changing filters on air

samplers, area smears and swabbing air lines that were to be used by

the platform workers to ensure that they were not contaminated. None

of this work required physical entry into the RCZ.

At approximately 0530 hours0.00613 days <br />0.147 hours <br />8.763227e-4 weeks <br />2.01665e-4 months <br />, the platform crew of two workers and a

platform HP technician entered lower containment.

The two HP

technicians then present assisted the two workers in donning bubble

hoods and setting up communications after which the platform crew

ascended the ladder to the S/G "D" platform.

At approximately 0615, the first S/G jump was made for purposes of

inspection and measurement preparatory to nozzle dam installation. The

second jump occurred shortly thereafter for the purpose of reaming out

the nozzle dam insert holes. A tool with a rotating wire brush was

used for this activity. Since the licensee required the use of the

" buddy system" for all S/G entries, the first worker remained on the

platform while the second worker was reaming the holes.

The platform

HP technician acted as timekeeper. When the second worker exited the

S/G, the first worker descended the ladder to the RCZ below.

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At approximately 0645 hours0.00747 days <br />0.179 hours <br />0.00107 weeks <br />2.454225e-4 months <br />, the general area HP technician in lower

containment donned a disposable coverall and an extra pair of rubber

gloves preparatory to assisting the first platform worker in removing

part of his protective clothing. When the worker came down the ladder,

the HP technician stepped onto the outer edge of the RCZ and helped the

worker remove - his bubble hood and cut him out of his wet suit. The

technician then removed the disposable coverall and extra set of'

gloves.

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Between 0700 and 0815, the general area HP technician continued to

perform radiological surveillance activities in lower containment (air

sampling and smears survey).

At 0815, the technician exited

containment and removed all protective clothing at the HP control

point. Upon monitoring, the technician was found to be contaminated on

the inside calf of the right leg. While at the control point, the

technician used tape to try to remove the contamination but was

unsuccessful in doing so.

Consequently, disposable coveralls was

donned and the technician was escorted to the " hot" shower by a second

HP technician.

An HP Supervisor was also dispatched to the " hot"

shower.

In the shower room, a full body survey of the HP technician was

conducted and three areas of contamination were identified: (1) inside

calf of the right leg which measured 60 millirad / hour, (2) outside of

the right arm just above the elbow which measured 12 millirad / hour and

(3) the rib cage just underneath the armpit which measured 300 counts

per minute (cpm). After the first shower, the body activity had been

reduced to approximately 300 cpm and after a second shower, body

activity had been reduced to less than 150 cpm.

Decontamination was

completed by 0855 hours0.0099 days <br />0.238 hours <br />0.00141 weeks <br />3.253275e-4 months <br />.

During the showering process, several towels had been torn into small

pieces to be used as wash cloths. It was on one of these pieces that

the contamination of highest activity was later recovered.

The

contaminated area of the towel reading 60 millirad / hour on a R0-2

survey meter, was cut out, placed in a petri dish and sent for gamma

isotopic analysis.

The contamination was found to be a single

microscopic particle composed of a variety of radionuclides as follows:

xenon-131 m;

xenon-133;

cobalt-58;

zinc-69 m;

silver-108 m;

neptunium-239;

iodine-131,

132,

133;

zirconium-95;

niobium-95;

technetium-99 m; ruthenium-103, 106; cesium-134, 137; barium-140;

cerium-141,

144;

and

lanthanum-140.

The

total

activity was

0.802 microcuries. The licensee postulated that the particle was a

piece of zircalloy cladding.

The licensee had conducted an investigation to determine how and when

the technician became contaminated.

Due to a history of " hot"

particles at the facility, the licensee had initiated an aggressive

program for monitoring laundered protective clothing and felt confident

that the particle had not originated from the protective clothing.

Since particles, primarily cobalt-60 in composition, had been found in

laundered protective clothing previously, the licensee had purchased

and installed a laundry monitor at the facility in February 1986. The

monitor had a row of six plastic scintillation detectors and a conveyor

belt which moved the clothing underneath the detectors.

The lower

limit of detection for the top of the clothing was 100 nanocuries of

cobalt-60 and on the bottom of the clothing, 200 nanocuries of

cobalt-60. The monitor was set to alarm at approximately 20 cpm above

background levels of 20-30 cpm. These levels were significantly below

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that of the recovered " hot" particle.

The inspector reviewed the

calibration records for the laundry monitor.

The licensee determined that based on previous area surveys and the

nature of the work performed by the technician prior to entry into S/G

"D"

RCZ, that no opportunity for exposure to high levels of

contamination had existed. The first work performed by the technician

associated with high levels of contamination was cutting the S/G jumper

from his wet suit which took place at approximately 0700 hours0.0081 days <br />0.194 hours <br />0.00116 weeks <br />2.6635e-4 months <br />.

Since

decontamination of the HP technician was complete at 0855 hours0.0099 days <br />0.238 hours <br />0.00141 weeks <br />3.253275e-4 months <br />, the

licensee used an exposure time of one hour and fifty five minutes to

calculate total exposure. Based on the one hour and fifty five minute

stay time, an exposure of 4500 millirad beta and 25 millirad gamma

radiation was estimated to the skin of the whole body distributed over

a one square centimeter area. When added to the previous skin of the

whole body exposure accumulated during the calendar quarter of

315 millirem, a total dose to the skin of the whole body was determined

to be 4,840 millirem.

Examination of the Radiation Work Permit (RWP) records revealed some

confusion as to which RWP was in effect for the HP technician and

,

consequently what

the

protective

clothing

requirements were.

Examination of the contaminated individual's dose card for the time of

interest showed that containment entry had been made under RWP No.

86-1162, Unit 1 Reactor Building-Eddy Current Testing S/G "D," while

examination of the RWP time sheets showed that the individual had

signed into the Reactor Building (RB) on RWP 86-1167, "ID" S/G Nozzle

Dam Installation.

The Station Health Physicist stated that the

individual should have been signed into the RB on RWP 86-1183,

Miscellaneous Outage Entry into Lower Containment and Pipe Chase. The

distinction of which RWP was applicable to the worker was of importance

since the RWP was the instrument utilized by the station to specify the

radiological requirements for a job.

The licensee confirmed that the use of RWP 86-1162 was an error since

at the time of the inspection eddy current testing had not been

performed on Unit 1 S/G "D."

HP personnel stated that RWP 86-1167 was

written for S/G workers who were performing tasks on the platform and

making entries into the S/G. Since the general HP technician was not

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involved in actual platform work, but remained in lower containment to

perform routine task and to support the jump crew, it appeared that her

work activities were not covered by RWP 86-1167. In addition, the HP

technician was not in compliance with RWP No. 86-1167 which required

the wearing of one cloth coverall and one plastic suit.

Since the

licensee indicated that the technician should have used RWP 86-1183,

the protective clothing requirements specified for the RWP were

examined. As RWP 86-1183 was initially written on May 15, 1986, the

technician was in compliance with regard to protective clothing

requirements.

However, the Station Health Physicist stated that

RWP 86-1183 had been verbally amended to require that technicians who

cut S/G workers from wet suits don a wet suit themselves prior to any

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cutting. The time and date of this verbal amendment were unknown since

no record had been made, and RWP 86-1183 was not revised to reflect the

new requirements.

It was also learned that after contamination

problems had been identified in lower containment after S/G "A" work

early in the week of May 26, 1986, RWP 86-1183 had been again verbally

amended to require all workers entering lower containment to wear two

sets of cloth coveralls and a respirator. The exact time and date of

this verbal amendment was not known since this change, too, was never

documented, but the consensus of the HP staff was that verbal

instructions had been issued prior to the May 29, 1986, contamination

event. The inspector discussed this issue with the HP technician who

had been contaminated. The technician stated that she had been unaware

of the upgrade in protective clothing requirements to the RWP and had

thought that she was in compliance.

She further stated that prior to

cutting the S/G worker from his wet suit that she had donned the

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disposal coverall and an extra pair of gloves to provide greater

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protection for herself and by doing so though that the protective

clothing she had on exceeded those of the RWP.

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The Station Health Physicist also stated that after the May 29, 1986,

event, RWP 86-1183 was again verbally amended to require all entries

into Unit I lower containment to wear, among other items of protective

clothing, one cloth coverall and one plastic suit. This change was

again undocumented so that the exact time and date of the new

requirement was not known. The inspector reviewed RWP 86-1183 at 1330

hours on June 4,1986, and none of the more restrictive radiological

requirements, as specified above, had been documented by a RWP

revision.

Technical Specification (TS) 6.8.1 requires that written procedures be

established, implemented, and maintained covering applicable procedures

recommended in Appendix A of Regulatory Guide 1.33, Revision 2,

February 1978.

Appendix A, Regulatory Guide 1.33, Paragraph 7.e.1 recommends that the

licer.see have radiation protection procedures to control access to

radiation areas including a radiation work permit system.

The inspector reviewed licensee procedures related to the RWP program.

HP Manual, Section 2.1, Radiation Exposure Control, Paragraph 2.1.2.d

stated that all

personnel are responsible for following all

instructions and directions presented by HP including adherence to RWP

requirements. Paragraph 2.1.3.3 of the same procedure stated that in

regard to violation of requirements of RWPs, personnel did not have the

prerogative of deciding whether or not to meet one or more of its

requirements and that permission for a temporary deviation from RWP

requirements was required.

Further, the deviation from requirements

was to be specified in the Shift HP log.

The inspector asked to

examine the Log entry which permitted the HP technician to deviate from

the requirements of RWP No. 86-1183. The licensee stated that no such

Shift Log entry existed in that deviations from RWP requirements were

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for the relaxation of radiological requirements of RWPs and were never

intended to apply to situations where protective measures for personnel

had become more restrictive due to changing radiological' conditions.

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Health Physics Manual Section 2.4, Radiation Work Permits, stated that

the RWP was a tool utilized to specify the radiological requirements

for any job on radioactive or contaminated equipment within the

Radiation Control Area of the station. Paragraph 2.4.1 stated-that the

RWP was issued for a particular job in a particular area and on a

specific piece of equipment or on a specific component and that the RWP

contained the specific protective clothing requirements.

Since RWP 86-1183 protection clothing requirements. had been verbally

revised several times prior to the contamination event on May 29, 1986,

discussions were held with licensee representatives concerning

mechanisms in place for control and review of RWP revisions.

The

licensee indicated that HP Manual Section 2.4 did not address RWP

revision and that the changes in requirements for RWP 86-1183 had been

promulgated via the various HP supervisors after instructions to do so

by the Station Health Physicist.

Although conversations with the

concerned HP Supervisor indicated that the requirements had been

communicated, the HP technician who had become contaminated stated that

she was unaware of the upgrade in radiological requirements for the

RWP.

Consequently, as written on May 15, 1986, and in effect on

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May 29, 1986, neither RWP 86-1167 nor RWP 86-1183 covered the scope of

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the work actually performed by the technician in lower containment,

i.e.,

cutting S/G workers from their wet suits after S/G entry, and

therefore neither RWP was applicable to the job being performed by the

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technician.

The inspector informed the licensee that failure to

specify appropriate radiological requirements for individuals working

in Unit i lower containment as required by HP Manual Section 2.4 would

be considered an apparent violation of TS 6.8.1 (50-369/86-15-01). At

the time of the exit interview, the Station Health Physicist informed

the inspector that all RWPs dealing with Unit 1 lower containment had -

baen revised to reflect the most current protective ' clothing

requirements.

4.

Second Contamination Event

a.

Synopsis of Event

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A second contamination event occurred on June 4,

1986.

A licensee

mechanic who had been working in Unit I upper containment was found to

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be contaminated upon exit from the RB.

The contamination was

identified as a single microscopic particle of cobalt-60 with a total

activity of 1.96 microcuries. The individual was decontaminated and a

dose to the skin of the whole body of 2180 millirem was assigned the

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b.

Review of Event

On June 4, 1986, at approximately 1220 hours0.0141 days <br />0.339 hours <br />0.00202 weeks <br />4.6421e-4 months <br />, the mechanic entered the

HP control point. He proceeded to tne change room where he dressed in

protective clo+hing pursuant to RWP 86-1196, Removal and Replacement of

Unit 1 Reactor Head. Interviews with the individual indicated that he

was dressed in a'cordance with RWP requirements. The mechanic entered

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Unit I upper containment at approximately 1300 hours0.015 days <br />0.361 hours <br />0.00215 weeks <br />4.9465e-4 months <br /> and between 1300

and 1530 hours0.0177 days <br />0.425 hours <br />0.00253 weeks <br />5.82165e-4 months <br />, he assisted the crew in the reactor cavity by lowering

tools and directing the polar crane. At apprcximately 1630 hours0.0189 days <br />0.453 hours <br />0.0027 weeks <br />6.20215e-4 months <br />, the

individual donned a particulate respirator and descended to the floor

of the reactor cavity to assist in unwrapping sandboxes, square covers

which prevent leakage from the reactor cavity when in place and which

are installed prior to cavity flooding.

These covers had been stored

wrapped in three layers of Herculite since the last refueling outage.

This activity was completed at approxiraately 1630 hours0.0189 days <br />0.453 hours <br />0.0027 weeks <br />6.20215e-4 months <br />, at which time

the worker ascended from the cavity to the RCZ at the top. At this

point, the worker removed one outer set of rubber gloves, one pair

rubber overshoes, one pair of plastic booties, one hood and his

respirator. He made his way directly to the hatch exit and removed the

remainder of his protective clothing, one hood, one pair of rubber

gloves, two sets of cloth coveralls, one pair of plastic booties and

one pair of cotton glove liners.

When monitoring himself for

contamination using an RM-14, off-scale readings were observed. The

worker donned a disposable coverall and was sent to the " hot" shower.

A whole body survey was performed using a R0-2 ion chamber and an

exposure rate of 176 millirad / hour beta and 1.5 millirad / hour gamma

radiation was measured in the right groin re ion.

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The spot or particle of contamination was removed from the worker by a

single wipe of the area with a damp paper towel. Decontamination was

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complete by 1700 hours0.0197 days <br />0.472 hours <br />0.00281 weeks <br />6.4685e-4 months <br />. Isotopic analysis of the material showed the

presence of a single radionuclide, cobalt-60, with a total activity of

1.96 microcuries.

The licensee conducted an investigation of th~ event and determined

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that for reasons cited previously, the contamination most probably

could not have arisen from laundered protective clothing. Based on the

fact that the worker was wearing two sets of cloth coveralls and was

not performing extremely physical work which would have encouraged

heavy sweating, the licensee determined that it was not reasonable to

assume that the cobalt-60 particle could have worked its way through

two sets of coveralls, a pair of modestry shorts and a set of

underwear. Consequently, the time most probable for contamination was

undressing at the RB hatch when the particle could have transferred

from the outer coveralls to the inner coveialls and finally to the

skin. The contamination event was considered to have occurred at the

time the worker removed his protective clothing at 1645 until

decontamination was complete at 1700 or 15 minutes.

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A dose to the skin of the whole body assigned the worker from the

particle was 2170 millirad beta and 10 millirad gamma radiation.

For

the second calendar quarter of 1986, the worker had previously received

1005 millirem to the skin of the whole body-which combined with the

skin dose from the particle gave a dose to the skin of the whole body.

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of 3185 millirem for the quarter.

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The inspector reviewed the licensee investigation report of the event,

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surveys of the area, RWP No. 86-1196 and licensee dose calculations.

The licensee stated that in the future, outer coveralls would be

removed at the RCZ at the top of the reactor cavity prior.to the worker

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exiting the area. The second set of coveralls would be removed at the

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No violations or deviations were identified.

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