ML20207K163: Difference between revisions

From kanterella
Jump to navigation Jump to search
(StriderTol Bot change)
(StriderTol Bot change)
Line 1: Line 1:
{{Adams
#REDIRECT [[IR 05000369/1986015]]
| number = ML20207K163
| issue date = 07/15/1986
| title = Insp Repts 50-369/86-15 & 50-370/86-15 on 860603-05. Violation Noted:Failure to Follow Radiological Protection Procedures
| author name = Hosey C, Revsin B
| author affiliation = NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
| addressee name =
| addressee affiliation =
| docket = 05000369, 05000370
| license number =
| contact person =
| document report number = 50-369-86-15, 50-370-86-15, NUDOCS 8607290350
| package number = ML20207K116
| document type = INSPECTION REPORT, NRC-GENERATED, INSPECTION REPORT, UTILITY, TEXT-INSPECTION & AUDIT & I&E CIRCULARS
| page count = 9
}}
See also: [[see also::IR 05000369/1986015]]
 
=Text=
{{#Wiki_filter:'
                                                      e
  -
      *
          pS K8Cg                                      UNITED STATES
      g            #o                    NUCLEAR REGULATORY COMMISSION
    ['                n                                REGION il
    3                  j                        101 MARIETTA STREET, N.W.
    *                                            ATL ANTA, GEORGI A 30323
                      g
      %, " * * *. /                                  jut 16IN6
    Report Nos.:          50-369/86-15 and 50-370/86-15
                                                                    .
    Licensee: Duke Power Company
                      422 South Church Street
                      Charlotte, NC 28242                      '
                                                                                ,
    Docket Nos.:          50-369 and 50-370                            License Nos.:    NPF-9 and NPF-17
    Facility Name: McGuire
    Inspection Conductec        :    June 3-5, 1986
    Inspectors:                    j -h                                                  7hI!Ob
                                                                                          Date Signed
                      B.    Re9N/
    Approved by:                                                                      7[/G b d
                        C. M. Hos6 # Section) Chief                                        Dat'e Signed
                        Division of Radiatiorl Safety and Safeguards
                                                      SUMMARY
I
    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.
                                                                                                  .
!
<
                                                                                                    a
                                                                                                          1
,
        8607290350 860716
        PDR    ADOCK 05000369    PDR
      >G
                  .-                                .                      __.        _ _      - -      -
                                                                                                          l
 
                                                                      ...  .
          -
  .
                                                  2
        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
i
              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.
J
                                                                                                  i
    . --      ,.    .--.      -.        -.        -  .  ..
                                                                - - -        _ _ _ .      -.. --.
 
  .    .
                                              3
                                                                  .
          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 hours, 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 hours 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.
              Between 0445 and 0530 hours, 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 hours, 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.                  4
                                                                                            !
            At approximately 0645 hours, the general area HP technician in lower          I
            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.
  , __  _            ,        -,-  .      _    _
                                                              _              -      _. -
 
. .
                                      4
    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 hours.
    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
 
  . .
                                        5
        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 hours. Since
        decontamination of the HP technician was complete at 0855 hours, 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
!        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
      -,                - _ _              . _ _ - -          __    -            _. . -
 
    _
                                                                          _. __ _ _ _ _ _ _ _ _ _ _ _            _
  .  .
                                            6
        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
        disposal coverall and an extra pair of gloves to provide greater
,
'
        protection for herself and by doing so though that the protective
        clothing she had on exceeded those of the RWP.
i                                                                                                                  l
;        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                                    ;
                                                                                                                  i
                                                                                                                  i
                                                                                                                  l
            -.    . _ . ,              .    ,    . - -  . . -      ,        , -.                  _ - -
                                                                                                            - --
 
  . _ -    .-                                              -                                    .
          .      .
4
                                                            7
                                                                                                          l
                        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.
                                                                .
                                          .
                        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
a
                        RWP.      Consequently, as written on May 15, 1986, and in effect on
,
                        May 29, 1986, neither RWP 86-1167 nor RWP 86-1183 covered the scope of
'
                        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
l                        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
                                                                                                          i
                        A second contamination event occurred on June 4, 1986.        A licensee        l
                          mechanic who had been working in Unit I upper containment was found to          l
                          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
'
                          worker.
                        s
i
i
                                                                                                          i
        -                  . ___    .        - . . _ _ _ _  .    . . . - . _ _ .-    -- -.  -  ...-.1
 
      _
.
  .
                                          8
    b.  Review of Event
        On June 4, 1986, at approximately 1220 hours, 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
                          c        with RWP requirements. The mechanic entered
        Unit I upper containment at approximately 1300 hours and between 1300
        and 1530 hours, he assisted the crew in the reactor cavity by lowering
        tools and directing the polar crane. At apprcximately 1630 hours, 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 hours, 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 res ion.
      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
                                                                          ~
      complete by 1700 hours. 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
      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.
                                                                                l
                  -            _            ..  --.      -    -          --
 
            __ .      . _                                                _  _    -._
    . . . .
                                                                              9
4
                                  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
t                                  skin dose from the particle gave a dose to the skin of the whole body.
'
                                  of 3185 millirem for the quarter.
.                                The inspector reviewed the licensee investigation report of the event,
                                    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
t                                exiting the area. The second set of coveralls would be removed at the
j                                  RB exit.                                                                                                          i
                                  No violations or deviations were identified.
r /
4
!
                                                                                                                                                      l
                                                                                                                                                      l
                                                                                                                                                      l
                                                                                                                                                      l
                                                                                                                                                      l
1
$
                  ,- ,, . - . - - .      ..3..,..  , , , - -, --,,,.-._,__y_-
                                                                          -    - m.    .---,- -.-,.-yy- -
                                                                                                            y , ,., - ...-- y -s .-, , , . , . .p, ,
}}

Revision as of 20:53, 6 December 2024

Redirect to:

Retrieved from "https://kanterella.com/w/index.php?title=ML20207K163&oldid=4036056"