IR 05000528/1988035
| ML17304A733 | |
| Person / Time | |
|---|---|
| Site: | Palo Verde  |
| Issue date: | 10/21/1988 |
| From: | Cillis M, North H NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| Shared Package | |
| ML17304A732 | List: |
| References | |
| 50-528-88-35, 50-529-88-37, 50-530-88-33, NUDOCS 8811160443 | |
| Download: ML17304A733 (38) | |
Text
U.
S.
NUCLEAR REGULATORY COMMISSION
REGION V
Report Nos.
50-528/88-35, 50-529/88-37 and 50-530/88-33 License Nos.
NPF-41, NPF-51 and NPF-74 Licensee:
Arizona Nuclear Power Project P.
0.
Box 52034 Phoenix, Arizona 85072-2034 Facility Name:
Palo Verde Nuclear Generating Station - Units 1, 2 and
Inspection at:
Palo Verde Site - Wintersburg, Arizona Inspector:
Approved by:
Inspection Conducted:
September 19-23, 1988 and October 3-12, M. Cil is, Senior Radiat n Specialist Ai, Q4-H.
S. North, Acting Chief Facilities Radiological Protection Section 1988
/o Z.g gg Date Signed
/o 2y d"
Date Signed
~Summar:
a.
Areas Ins ected:
This was a special inspection covering two incidents reported by the licensee on September 20, 1988, and September 27, 1988.
The September 20, 1988 incident involved an unauthorized entry into a Unit 3 locked high radiation area made by two contract workers on September 8, 1988.
The second incident involved a locked high radiation area in Unit 1 that was left open and unattended for a twelve minute period on September 26, 1988.
The inspection also included a review of actions taken by the licensee to correct violations and inspector concerns that were brought to the licensee's attention at the conclusion of previous inspections and at an Enforcement Conference held with the licensee on August 17, 1988.
Inspection procedures 30703, 92701, 92702 and 93702 were covered.
b.
Resul ts:
II In the areas inspected, the licensee s radiation protection program appeared to require significant additional management attention.
Significant weaknesses were observed in the posting and control of high radiation areas and locked high radiation areas.
A violation concerning an unauthorized entry into a locked high radiation area is discussed in paragraph 2.A through 2.F.
An additional weakness in the licensee's control of locked high radiation areas is discussed in paragraph 2.G.
A further weakness was exhibited in the area of procedure compliance.
A violation involving the failure to conduct ALARA reviews of REP's before they are issued is discussed in paragraph 3.
8811160443 88 j.027 PDR ADOCK 05000528 G
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DETAILS 1.
Persons Contacted ao Licensee Staff
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Haynes, Vice President, Nuclear Production D. Driscoll ".Assistant Vice President, Nuclear Production Support F. guinn, Director, Nuclear Safety and Licensing J. Zeringue, Plant Manager, Unit 2 E. Ide, Plant Manager, Unit 2 M.'utler, Director, ANPP Standards and Technical Support M. Allen, Plant Manager, Unit 1 A. Sousa, Manager, guality Audits and Monitoring D. Shriver, Manager, ANPP Compliance R.
Mann, Manager, Central Radiation Protection M. Sills, Supervisor, Radiation Protection Standards P. Hilmer, Manager, Radwaste Support H. Doyle, Manager, Radiation Protection, Unit 2 E.
Sneed, Manager, Radiation Protection, Unit 3 R. Oberdorf, Manager Radiation Protection, Unit 1 Mimmicks, Manager, Maintenance, Unit 3 Kirby, Manager, Site Services Brown, Supervisor, Training LeRoy, Electrical Supervisor, Unit 3 Waldrep, Lead Shift Technical Advisor (STA), Unit 3 Rackley, STA, Unit 3 R.
Rodriguez, Affirmative Action Supervisor, Employee Relations G. Papworth, Director, guality Assurance McGee, Central Radiation Protection, Support Supervisor b.
Contractor Staff Bartlett Nuclear Inc.
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H. Barley, C. R. H. P., Vice President, Health Physics Engineer/Consultant 2.
Volt Electrical C.
W. Gray, Electrical Technician A. A. Beemiller, Electrical Technician C.
Nuclear Re ulator Commission
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J. Polich, Senior Resident Inspector H.
Coe, Resident Inspector F. Melfi, Reactor Inspector, Region V Office
~ Denotes attendance at the September 23, 1988, exit interview.
+Denotes attendance at the October 7, 1988, exit intervie In addition, the inspector met and held discussions with other licensee
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and contractor personnel.
2.
Licensee Re orted Events (A)
Backcaround The inspection included a review of two incidents that were brought to the attention of the Region V resident office staff on September 20, 1988, and September 27, 1988, by the licensee.
The incidents are as follows:
(1)
Incident No.
On September 8-9, 1988, two Unit 3 maintenance electrician technicians (NETs) assigned to relamp the entire Radwaste Building entered high radiation areas (HRA) contrary to requirements prescribed on the Radiation Exposure Permit (REP).
One of the METs also entered the High Level Spent Resin Tank room La Locked HRA (LHRA)j during the September 8 entry using a
screwdriver to slide the lock bolt on the door clear of the strike plate.
General area radiation levels in the room ranged from 250 mrem/hr to 1200 mrem/hr at 18 inches.
Contact radiation levels ranged up to 3500 mrem/hr on the tank bottom.
(2)
Incident No.
A radiation protection technician (RPT) who had been assigned to provide continuous coverage in the Unit 1 cask laydown area of the radwaste building failed to verify that the gate was locked upon leaving the area.
The area was being controlled as a
LHRA in accordance with licensee procedures.
The area was provided with a lockable gate and flashing warning lights and was posted as a
HRA due to certain areas having radiation levels up to 1500 mrem/hr at 18 inches.
Another RPT, who had been assigned to perform a shiftly check of LHRAs, found the open door.
He checked the area to ensure that no personnel were in the area and then shut and locked the gate and reported his findings to the lead RPT.
The licensee's staff determined that the door had been left open for approximately 12 minutes.
(B). ~Findin s
(1)
Incident No.
1 - Se uence of Events (a)
On September 8, 1988, two contract NETs were assigned to relamp the entire Radwaste Building pursuant to a preventative maintenance (PM) work request number 00309093, task number 046949, dated August 29, 1988.
The PN listed radiation exposure permit (REP)
number 3-88-08A as the REP for accomplishing the work prescribed in the P (b)
The work description provided on the PM stated:
"Inspect lamps 100'VL 1, 120'VL 2, 140'nd roof.
Perform periodic maintenance per the applicable portions of the attached instruction."
(c)
The two METs had 2 to 3 years experience working at a commercial nuclear plant.
All of the METs nuclear experience had been at the Palo Verde Nuclear Generating Station.
(d)
Radiation work practices (RWP) training for both METs was current.
The individual that used the screw driver to obtain access to a LHRA had attended the licensee's computerized RWP, refresher training course on August 31, 1988.
The other individual had attended refresher RWP training in February 1988.
It should be noted that Procedure 75AC-9ZZOl, Rev.
7,
"Radiation Exposure and Access Control", Section 4.1 and 4.1.2 states that individuals have the responsibility for "Adhering to all radiation protection instructions, including those on Radiation Exposure Permits."
Section 5. 1. 1 of the procedure states:
"All personnel who enter the Radiological Controlled Area must read and sign-in on the appropriate REP.
By signing in they indicate they have read and understand the requirements
.
and will comply.
Personnel shall read their appropriate REP prior.to each entry to determine whether it has been revised."
Procedure 75AC-9ZZ01 requires that personnel need to sign in on an REP only upon initial entry into an radiologically controlled area and then whenever the REP has been revised.
The inspector noted that one of the METs had signed in on REP 3-88-0008A on August 1, 1988, and the MET who had used the screwdriver signed in on the REP on August 13, 1988.
The instructions contained in REP 3-88-0008A dated February 5, 1988, entitled "Minor Work In Clean and Contaminated Areas" specifically stated:
"No entry into high contamination, high radiation, locked high radiation or areas requiring respiratory protection."
Sequence of events continued:
(e)
The METs stated that on September 8, 1988, they read the REP, informed radiation protection (RP) that they were going to relamp the Radwaste Building and then started scoping out the areas on the 140'evel requiring relamping.
It should be noted that the inspector had noted from previous inspections that radiation protection personnel routinely asked the inspector very specific questions prior to allowing the inspector authorization to enter radiologically controlled areas.
guestions normally asked were:
Do you intend to enter
contaminated areas, HRA's, LHRA's and what is the purpose and nature of your work?
The communication that occurred on September 8, 1988, between the METs and radiation protection personnel is unclear.
The RPT on duty stated he did not remember talking to the METs, however; he stated that he did remember seeing the METs around the control point entry area on September 8 and 9, 1988.
Upon arriving at the Waste Decay Tank Room on the 140'evel, the METs stated that they encountered the following posting:
(1)
DURING CERTAIN PLANT CONDITIONS (3)
DOSE RATE METER REQUIRED FOR ENTRY (4)
CONTACT RADIATION PROTECTION PERSONNEL FOR REQUIREMENTS TO BE MET PRIOR TO ENTRY" The METs assumed that since they had been allowed to enter the area, their initial contact with Radiation Protection personnel was sufficient for all radiation protection war ning signs posted in any areas they encountered during the performance of the relamping PM.
They proceeded to the Radwaste Control Room in order to borrow a dose rate meter from the on-shift Operations Support Lead (OSL).
The OSL stated that he questioned the METs as to whether the job had been discussed with radiation protection and if they were working under the proper REP.
The METs assured the OSL that they met those requirements.
The METs then proceeded to enter the HRAs on the 140'ven though the REP did not authorize entry.
The METs returned the dose rate instrument to the OSL after completing their relamping survey on the 140'..
They then proceeded to continue their relamping survey of the 120'nd 100'evels.
As the NETs approached the High Level Spent Resin Tank room, they noted that the door was locked and was posted as follows:
"(1) HIGH RADIATION AREA (2)
CONTACT RADIATION PROTECTION PERSONNEL FOR REQUIREMENTS TO BE MET PRIOR TO ENTRY."
One of the METs then proceeded to use a screwdriver to slide the locking bolt clear of the strike plate, thereby, gaining entry into the room.
The METs partner challenged the MET's use of the screwdriver; however, the MET was reassured by his partner that it was
"OK".
The MET using the screwdriver entered just long enough (5 to 10 seconds)
to make a quick visual inspection of the room and then exited the area.
The
door was relocked and the MET checked his self indicating dosimeter for any exposure (none was.indicated).
On September 9, 1988, the METs returned to begin the relamping effort following their initial inspection of the previous day.
The entry was made under the same REP and the METs proceeded to relamp the 140'evel.
The METs completed the 140'evel relamping on September 9, 1988.
The METs entered the same HRAs.
on the 140'evel on September 9, 1988, that had been.,entered on the previous day.
The relamping was resumed on September 12, 1988, on the 120'nd 100'levations.
As the NETs were about to enter the High Level Spent Resin Tank room their supervisor'ame by on a routine inspection of work in progress and inquired if they had checked with Radiation Protection (RP) for permission to enter the LHRA.
The METs stated that they informed RP that they were relamping the whole Radwaste Building.
The supervisor replied that they had better check for permission to enter that particular room.
One of the METs contacted RP and inquired about entry into the room, and was informed that entry was prohibited due to a 3000 mrem/hr radiation field in the room.
The METs then discussed this information and decided to inform RP of the entries they had made into HRAs and the LHRAs September 8-9, 1988.
(2)
Incident 81 - Initial Corrective Action Initial corrective action taken by the licensee is as follows:
(a)
The METs dosimetry equipment was processed.
The dosimetry equipment indicated no exposure.
(b)
A Radiological Controls Problem Report describing the event was prepared.
(c)
The workers were disqualified for further controlled area access and were required to attend the licensee's initial Radiation Worker Practices training course.
(d)
A Special Plant Event Evaluation Report (SPEER) 088-03-005 was initiated.
All involved personnel were interviewed by the Unit 3 Plant Manager and the licensee's staff appointed to conduct the SPEER evaluation.
The SPEER evaluation was still in progress at the conclusion of this inspection.
(e)
The Unit 3 Radiation Protection Manager issued a letter on September 20, 1988, to the Operations Support Group regarding the use of dose rate meters in Unit 3.
The letter emphasized that under no circumstances were dose rate meters to be given to anyone outside the Operations Support Grou i
(f)
On October 4, 1988, the Unit 3 Plant Manager issued a
memorandum to Unit 3 personnel.
The letter reemphasized the need for workers to read and understand REP's prior to each entry, obey radiological postings, such as "contact RP prior to entry", to fully understand the nature and scope of the work to be performed, and the need to improve communication between workers and radiation protection personnel.
(g)
The posting at the entrance to the Unit 3 High Activity Spent Resin Tank room was changed to read "Locked High Radiation Area."
(h)
Three signs were installed on the 140'evel of Unit 3 reminding personnel to read the REP and check with radiation protection prior to entering Radiologically Controlled Areas.
(i)
The Unit 3 Radiation Protection Manager (RPM) and the MET's supervisor discussed the incident with their staff.
(j)
The Chemistry and Radiation Protection Manager held an interface meeting with each of the Unit 1, 2 and 3 RPM's on October ll, 1988 to discuss the event and short term and long term corrective actions necessary to prevent recurrence.
(k)
The Supervisor of Radiation Protection Standards issued a
letter on October 12, 1988, to each of the Unit Radiation Protection Managers and Lead Radiation Protection Technicians.
The letter described the occurrence and need for Radiation Protection Technicians to improve their communications with personnel requesting permission to enter Radiologically Controlled Areas.
(1)
An insert was added to, all locked high radiation area postings to reflect that dose rates were in excess of 1000 mrem/hr and the requirement to contact RP prior to entry.
The inspector determined from discussions and observations that Unit 1 and 2 personnel were generally aware of the event; however, the corrective actions taken to prevent a recurrence at Units 1 and 2 were not consistent with the same actions implemented in Unit 3.
The inspector discussed the incident at the exit interview.
The inspector added that the corrective actions to prevent a
recurrence did not appear to be timely or consistent from Unit to Unit.
The inspector informed the staff of the Unit 3 Plant Managers concerns that postings with the words "Contact RP Prior to Entry" (see paragraph (3)(j) below)
may be meaningless and that Radiation Protection procedures were generically weak.
The resident inspector asked the representatives attending the exit interview what action or steps were taken to assure that
workers understand the radiological requirements and how to conduct their activities in accordance with good health physics practices.
The resident asked what effort was made to inform workers that the actions of the METs was an unacceptable practice.
The licensee's staff in attendance could not provide reasonable responses to the resident inspectors questions.
The Region V inspector added that it appeared, from both the licensee's and NRC's review of the incident, that no planned action was taken to determine whether or not there were generic implications to the incident that required attention at all three Units.
(3)
NRC Interviews and Additional Information A regionally based and the senior resident inspectors interviewed the two METs.
Additionally the regionally based inspector interviewed the Operations Support Lead who had loaned the METs the dose rate meter on September 8 and 9, 1988.
The RPT on duty when the entries were made by the METs was also interviewed and discussions were also held with the Unit 3 Plant Manager and the MET's supervisor.
Additionally, survey records of Unit 1 and 2 High Activity Spent Resin Tank room were examined.
The typed statements prepared immediately after the event by involved individuals; such as the METs, RPTs and Operations Support Lead were also reviewed.
The results of the above inspection efforts were as follows:
,(a)
The METs said they had read the REP prior to each entry made on September 8,
9 and 12, 1988.
(b)
The METs said that they are primarily assigned at Unit 3; however, on occasion they.had worked at Units 1 and 2.
(c)
The MET who borrowed the dose rate meter from the OSL originally informed the inspectors on September 21-22, 1988, that he had borrowed the instrument from the OSL because he thought the OSL was part of the radiation protection organization.
Both METs made this statement to the NRC inspectors on several occasions during the interview in the presence of the Unit 3 Maintenance Manager.
The MET subsequently stated he had borrowed the instrument from the OSL because of a problem he had experienced 3 to 4 months earlier at which time the radiation protection group had directed him to borrow an instrument from the Operations Support Group because they didn't have any to loan.
The MET said that on September 8-9, 1988, he went directly to the OSL to borrow the instrument because of his earlier experience.
The inspector asked the MET if he had asked the Lead Radiation Protection Technician (LRPT) for an instrument or had
informed the LRPT that he intended to borrow the instrument from the OSL.
The MET replied in the negative.
The MET said that the OSL who had loaned him the dose rate meter told him that he would only need the instrument on the 140'levation.
(d)
A written statement of events that was prepared on September 13, 1988, by OSL who had loaned the dose rate meter to the MET states in part:
"Twice last week, while I was the dayshift Operations Support Lead, it was requested that Operation Support loan the Electrician the dose rate meter retained by Operations Support to assist in their relamping task.
On both occasions, I was told by the electricians that RP was "temporarily unavailable" to go to the instrument issue room, so loan of the Operations Support dose rate meter was requested."
The OSL went on to state that the MET was questioned as to:
"a) Being entered on the appropriate REP and has discussed with RP the areas to be relamped for dose rates and entry requirements.
That the 140'levation of the Radwaste Building was the only place that the dose rate instrument would be taken..."
The inspector met with the OSL on October 3, 1988.
His statement of September 13, 1988, was reviewed with the OSL at which time the inspector was informed that the information was accurate to the best of his knowledge.
The inspector reviewed the same information with the METs to clarify inconsistencies between the statements they had made to the NRC during an earlier interview and the statement made by OSL.
The MET reiterated the experience that he had 3-4 months earlier.
The MET could not give a reason as to why he did not ask to borrow an instrument directly from RP.
(e)
The inspector met again with the OSL on October 5, 1988, to review the information he had related to the NRC inspector two days earlier.
This time the OSL was not certain what words were spoken between himself and the MET who requested the loan of the dose rate meter on September 8-9, 1988.
The OSL tended to agree more with the subsequent statement that was made by the MET regarding the experience he had
to 4 months earlier.
(f)
The inspector noted that the MET's written statement relating the experiences he had 3 to 4 earlier were not
included in the original typed statements (dated September 20, 1988) provided to the inspector during the week of September 19-23, 1988.
The statement related to the MET's earlier experiences were provided in a second set of statements provided to the inspector during the week of October 3-7, 1988.
The only difference, between the two statements was one section addressing his prior experiences.
The METs stated that they had routinely used a screwdriver to gain access to rooms when the plant was under construction and during the pre-operational phase.
He added that this practice was common at those times; however, this was the first occasion that he had used a
screwdriver to gain entry into a locked area since the plant entered the operational phase.
The METs did not know of anyone else that was currently in the practice of using a screwdriver to gain entry to a locked area.
The inspector asked the MET if he had read the radiological posting that was strung across the entrance to the room.
The MET said he had read it and felt that he had met the conditions that were posted, in that he had notified radiation protection prior to entering the area that they intended to rel.amp the Radwaste Building.
The inspector asked if the door was locked.
The MET replied that it was locked and it was posted; but, h'e still decided to use a screwdriver because he didn't know it was a locked high radiation area.
The MET repeated this statement several times during the interviews.
The MET was unable to explain why he took the actions that he did other then to say "inattention-to-detail".
The MET said that he thought that the posting on the High Activity Spent Resin Tank room was less restrictive than the posted high radiation areas on the 140'levation which required a dose rate meter for entry whereas the posting on the High Activity Spent Resin Tank room did not require a dose rate meter.
The inspector asked the METs why they entered HRAs on the 140'levation and the LHRA on the 100'levation in view of the fact that the REP which they signed in on, and supposedly read, did not authorize entry into HRAs or LHRAs.
The METs replied "inattention-to-detail".
One MET added that he may have forgotten what he read on the REP by the time he got to the work area.
During an earlier interview with the same MET that made this statement he had informed the inspectors that he could not remember if he had read the entire REP.
The Unit 3 Plant Manager did not condone the action taken by the METs; however, the Plant Manager said that the METs actions were plausible based on the following reasons:
(j.)
Poor communications between the METs and RP personnel.
I (2)
Inadequate training.
(3)
Inexperience of the METs.
(4)-
Radiation Protection procedures were generically weak.
(5)
Inconsistencies in posting of HRA verses LHRA.
The Plant Manager also felt that the posting "Contact RP" may be misleading.
The Plant Manager felt the posting should be more specific to include words such as
"no entry", etc.
(6)
Past history for gaining entry into locked areas during construction and pre-operational phases.
(7)
The earlier organization which could lead the METs to believe the Operations Support Group was part of the RP organization.
The Plant Manager also felt that the two METs could have failed to report the event.
The inspector.informed the Plant Manager that the METs were fortunate that they were not assigned to relamp the High Activity Spent Resin Tank rooms in Units 1 and
where general area dose rates at 18" inches measured in excess of 25,000 mrem/hr with contact readings at 100,000 mrem/hr or greater.
The inspector added that when all the facts were considered it appeared that the METs actions were willful and deliberate and indicated a complete disregard for radiation protection and their own safety.
The Unit 3 Plant Manager disagreed with the inspector's conclusions.
He added that it would be necessary to carefully weigh the METs reporting of the event when they probably could have failed to do so and examine their understanding of the seriousness of their actions.
The inspector stated that it appeared that they were forced to report the event after being confronted by their supervisor as the MET was about to reenter the High Activity Spent Resin Tank room on September 12, 1988, using the same method that was used on September 8, 1988.
C.
- Additional Information A review of the licensee's Radiological Controls Problem Report number 3-88-006, dated September 12, 1988 stated that the MET who had used the screwdriver was qgestioned about the knowledge of radiation protection postings.
The report stated:
"He did not seem to understand the meaning and significance of various radiation protection postings."
It should be noted that an inspectors concern was brought to the licensee's attention in paragraph 8(f) of Region V Inspection Report 50-529/88-22.
The concern, listed as open item 50-529/88-22-08, noted that the workers knowledge in the area of high radiation area control was questionable.
An examination of the licensee's Radiological Work Practices (RWP)
training lesson p1an used for instructing workers pursuant to the requirements prescribed in 10 CFR 19. 12 was conducted.
The examination included a review of the training lesson plan and training manuals that are issued to personnel attending the course.
The examination disclosed that the RWP training course had been accredited by INPO and was consistent with 10 CFR Part 19. 12 requirements.
The training supervisor informed the inspector that the event was in the process of being reviewed by the training group to determine what improvements could be made to the current RWP training program.
A review of the licensee's past history related to posting and control of radiation areas, high radiation areas and locked high radiation areas for the period of July 1, 1987 to October 7, 1988, was conducted.
The review disclosed the following:
INSPECTION REPORT NO.
FINDING 50-528/87"24 A worker, not equipped with monitoring equipment prescribed in Technical Specifications 6. 12. 1 and not accompanied by an individual qualified in radiation protection entered the Unit 1, LPSI "B" pump room, a posted high radiation area.
50"528/87"40 On November 17, 1987, and again on November 19, 1987, the Unit 1 West Mechanical Penetration Access room of the Auxiliary Building had two small areas where the intensity of radiation measured between 100 and 800 mrem per hour and were not barricaded and conspicuously posted as high radiation areas.
50-529/88-22 An unlocked door provided access to an area on the 100'o 112'evel of the Unit 2 Radwaste Building, High Level Drum Storage and Transfer Cart ar ea, where the intensity of radiation at 18 inches measured up to 3500 mrem per hour.
50-529/88-26 (1)
The outlet end of the "A" Shutdown Heat Exchanger had whole body radiation levels of 140 mrem per hour
at 18 inches, but was not effectively barricaded.
(2)
Radiation levels of 120 mrem/hr at 18 inches from the "B" Shutdown Cooling valve, SlB-V910, was not barricaded on one side and was not conspicuously posted.
(3)
Radiation levels of 150 mrem/hr at 18 inches from Shutdown Cooling valve, SlA-V172, and piping, EM-UV-65, were not conspicuously posted and two sides were not barricaded.
The inspector noted that the licensee's response to the findings identified in Inspection Reports 50-528/87-24 and 50-528/87-40 included the following:
(1)
Res onse to 50-528/87-24
"The PVNGS Plant Manager has issued a memorandum to all ANPP personnel to reemphasize the importance of adhering to the requirements for entry into high radiation areas."
(2)
Res onse to 50-528/87-40
"...Other instances of improper frisking and improper segregation of protective clothing indicate that the employees involved in work activities within radiological controlled areas were not sufficiently sensitive to the established controls or the necessity of safe radiological work practices.
Based upon this conclusion, an aggressive program is being initiated to upgrade the awareness and increase the overall sensitivity of radiological work practices by each employee responsible for the overall program implementation.
This program includes:
(a)
A letter will be issued to each ANPP employee from the Executive Vice President which stresses 'that ANPP's number one priority of safety includes radiological safety.
(b)
The production of a video tape by Executive Level management which will include reinforcement that ANPP is committed to safe radiological work practices.
All ANPP employees will be required to view the tape.
(c)
An issue of the "Reactor" (a monthly project publication)
will include a section stressing the importance and necessity for safe radiological work practices.
(d)
Accelerated disciplinary action for individuals who violate established radiological work practice C
Because of the extensive scope of the proposed program the effectiveness will be evaluated approximately six months after full implementation.
Additional actions wi 11 be implemented if necessary based upon that review.
ANPP believes that this aggressive approach will be successful in not only addressing the specific deficiency identified in the Not'ices of Violation but will be successful in upgrading the entire Radiation Protection Program."
The inspector concluded that the licensee's corrective actions appeared to be ineffective.
Conclusion The inspector brought the above observations to the licensee's attention at the exit interview.
The inspector stated that it appeared that the performance in the area of radiation protection was declining.
The inspector added that the declining trend appeared to be attributable to weak procedures, failure to follow procedures, and poor performance of the workers and staff.
The licensee was informed of the serious nature of the event in that they were fortunate it did not occur in Units 1 and 2 where the dose rates were substantially higher (e. g..
100 R/hr).
The inspector said that previous corrective actions appeared to have been untimely and ineffective.
The inspector reviewed and discussed the licensee s past history described in Section 2(D), above.
The inspector said it appeared that there was a generic issue associated with the control of radiation areas that needed to be resolved both on an interim and long term basis.
The inspector added that there did not appear to be any one individual or group that had a grasp of the situation and fully understood the problems that. required attention.
The inspector said that these problems have been brought to their attention through the routine NRC inspection process and at the recent Enforcement Conference held in Region V on August 17, 1988.
The inspector informed the licensee that it wasn't necessary to wait for an Enforcement Conference or Inspection Reports before taking corrective action.
The inspector asked if ANPP personnel knew what management goals and expectations were.
The inspector also asked if management holds workers and the staff accountable for their performance.
The inspector concluded by stating the actions taken by the MET's appeared to be a willful act and it showed that they had a
disrespect for radiation safety practices.
The inspector added that failure of the METs to comply with the instructions on the REP and RP postings was an apparent violation (50-530/88-33-01).
The Vice President, Nuclear Production acknowledged the inspectors concerns.
The Vice President stated that the worker's actions were totally unacceptable and will not be tolerated in the future.
The Vice President questioned the adequacy of the training program.
Me
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could not comprehend what would motivate anyone to do what the workers did in this event.
Licensee Event Re ort LER A copy of LER 3-88-005-00, dated October 12, 1988, describing the incident, discussed in this report as Incident No. 1, was received in the Region V Office on October 14, 1988.
A review of the LER indicates essential agreement with the description of the event included in this report.
It should be noted that
CFR 50.73,
"Licensee event report system" states in part (b), "Contents.
The Licensee Event Report shall contain:
... (4)
A description of any corrective actions planned as a result of the event, including those to reduce the probability of similar events occurring in the future."
A review of the LER established that it did not clearly state what measures have been taken to emphasize to personnel the importance of appropriate respect for locked high radiation areas.
The LER failed to state actions which have been or will be taken to inform personnel at all three Units that defeating the lock on a locked high radiation area is an unacceptable practice.
Incident No.
The inspector was informed that while a Radiation Protection Technician (RPT) was providing continuous coverage in the Unit 1 Transfer Cask area of the Radwaste Building on September 26, 1988, the RPT failed to shut and check locked the gate on the 112'levation after the work was completed.
The area in which the work was performed was in an area that was being administratively controlled as a locked high radiation area.
The area was appropriately posted and is equipped with a lockable gate and flashing lights pursuant to Technical Specification 6.12.2 requirements.
Another RPT, performing a shiftly check of locked high radiation area doors/gates and flashing lights found the door open.
The RPT verified that no personnel were in the area and then locked the gate before reporting the incident to the lead RPT.
A licensee investigation revealed that the door had been left open for a total of twelve minutes.
Radiation measurements of the area were obtained.
The survey data was reviewed by the inspector.
The licensee's investigation was still in progress at the time of this inspection.
The incident had been documented on a.Radiological Controls Problem Report as required by procedure 75AC-9ZZ12,
"Radiological Controls Problem Reports".
Radiation measurements in the area ranged from 0.1 mrem per hour in the Transfer Cask Area to as high as 1500 mrem per hour in the High Drum Storage Area that is separated by an eight to twelve foot high cubicle (see below)
and shield wal I
The Unit 1 Radiation Protection Manager informed the inspector that during the investigation it was learned that a month earlier, on August 25, 1988, a door located on the 100'levation, which provided access to the Radwaste Solidification Control Cubicle of the Radwaste Building was found open.
The door was also being administratively controlled as a locked high radiation area.
The event was recorded in the shiftly Radiation Protection log; however, a Radiological Controls Problem Report was not initiated as required by procedure 75AC-9ZZ12.
In addition, the Unit 1 Radiation Protection Manager stated that his review of the logs failed to identify the event at the time it occurred.
Radiation measurements in the cubicle at the time of the event were less than two millirem per hour.
The licensee s investigation related to this event was also in progress at the time of this inspection.
The cubicle has a
large penetration which provides access to the same Transfer Cask area as that involved in the unlocked door event found opened on September 26, 1988.
A tour of the involved areas was made by the inspector and licensee's staff.
The inspector noted that access to the actual high radiation areas would be very difficult since it would require climbing down a fifteen to twenty feet wall and then scaling another eight to twelve foot shield wall.
Another possibility would be to walk fifteen to twenty feet across the top of shield wall from the Transfer Cask area to the Drum Storage area.
The inspector concluded that the events were not in violation of NRC regulatory requirements.
They were; however, in violation of licensee procedures and provided additional examples of the concerns raised by the inspector in connection with Incident No. 1, above.
The inspector brought the above observations to the licensee's attention.
The inspector stated the two events demonstrate a
continuing decline in performance in the radiation protection program area.
The licensee's staff indicated that they planned to submit a voluntary report to Region V after their investigation of these events have been completed.
This item will be examined during a subsequent inspection (50-528/88-35-01).
3.
Inde endent Ins ection An independent examination was conducted for the purpose of determining if corrective actions addressing the concerns raised in connection with the licensee's ALARA program, as described in Region V Inspection Report 50-529/88-26, had been implemented.
These concerns were brought to the licensee's attention during an Enforcement Conference held in Region V on August 17, 1988, and a followup meeting held in Region V on September 14, 1988.
The Vice President, Nuclear Production, informed the Region V
staff at the August 17 meeting that the Unit Radiation Production Managers were fully responsible for RP practices at their assigned unit The inspector selected five to six Radiation Exposure Permits (REP) in Units 1, 2, and 3 to determine if the REP's were processed in accordance with procedure 75RP"9ZZ44, "Radiation Exposure Permits".
Procedure 75RP-9ZZ44, Section 6.4 states in part:
REP Preparation - ALARA Review 6.4. 1 The unit RP Manager or designee shall review the REP and determine whether an ALARA Review or Pre-Job briefing is required in accordance with 75RP-9ZZ94.
6.4.2 If an ALARA review is required and ALARA is unavailable, the RP Technician will complete an ALARA Pre-Job review to determine any dose reduction methods which could be used for that job.
6.4.2. 1 A time constraint (expiration date/time) will be placed on the REP to bring the Man-Rem total to 1 Man-Rem or less.
6.4.2.2 REPs of this nature will require close exposure tracking.
6.4.2.3 If the job must continue past the time limit established and ALARA is still not available, the original REP shall be terminated and a new REP originated following steps 6.4.2.1 and 6.4.2.2."
The examination disclosed that appropriate ALARA reviews had been conducted for the REPs selected in Units 1 and 3; however, the ALARA reviews for four of five REP's selected at Unit 2 were still incomplete at the time of this inspection.
Four of the five REPs were in effect prior to the time of the August 17, 1988, Enforcement Conference.
One of the REP's, originated on August 31, 1988, was implemented on September 22, 1988'he remaining three REPs were still posted and were being used at the time of this inspection.
The instructions of procedure 75RP-9ZZ44, Section 6. 4 were not followed:
The REPs were:
REP No.
2"88-0133A 2-88"0134A Title Unit 2 Operations-Routine Shift Tasks Unit 2 Chemistry-Routine Shift Tasks Effective Dates 7/1/88 to 12/31/88 7/1/88 to 12/31/88 2-88-0135A 2-88" 112D Unit 2 Radiation Protection - 7/1/88 to 12/31/88 Routine Shift Tasks Routine Radwaste Vendor 8/31/88 to 12/31/88 Services Group Work In Unit 2 Protected Area
The examination disclosed that REP 2-88-112D had been submitted to the ALARA group for a review approximately two weeks prior to the start of this inspection.
The ALARA group representative informed the inspector that the REP was returned to the Unit for revision.
It was never returned to the ALARA group and had apparently been placed in effect on September 22, 1988, without the required ALARA review being conducted.
The inspector discussed the above observations with the Unit 2 Plant Manager and Radiation Protection Manager and subsequently at the exit interview.
The Plant Manager informed the Radiation Protection Manager that in the future no REPs are to be put into effect unless the required ALARA reviews have been completed.
The Radiation Protection Manager brought the matter to the, attention of the Supervisor of Radiation Protection Standards.
The Radiation Protection Standards Supervisor assigned a
member of his staff to review procedure 75RP-9ZZ44 to clarify how ALARA reviews are to be accomplished.
The inspector informed the licensee's staff of the above observations.
The inspector stated that the observations demonstrate another example of the declining trend noted in the radiation protection area and another example of the failure to implement corrective actions in a timely fashion.
The inspector added that failure to follow the instructions in procedure 75RP-9ZZ44, Section 6.4 was an apparent violation (50"529/88-37"01).
Radiation Protection Pro ram Im rovements The inspector attended a meeting with the Director, ANPP Standards and Technical Support, Radiation Protection Standards Supervisor, and the Vice President, Bartlett Nuclear, Inc.
who has been engaged to conduct an in depth study of ANPP's Radiation Protection Program.
The Director, ANPP Standards and Technical Support informed the inspector of some plans that were being implemented to improve ANPP's Radiation Protection Program based on lessons learned from past performance.
Improvements include the following:
Fill the vacant site Radiation Protection Managers position as quickly as possible.
Even if it means fillin'g the position with a contractor.
Increase supervisory involvement at the job site by craft supervisors, Radiation Protection Leads, Radiation Protection Supervision, and ALARA staff members.
Monitoring to assure increased supervision is being provided.
Increased management control of radiation protection to promote site wide communications programs and radiological protection awareness and for improving radiation worker supervisory personnel trainin Increased surveillance of the Units radiation protection activities by the Radiation Protection Standards staff.
Strengthen radiation protection program implementing procedures.
Contracting for the services of the Vice-President of Bartlett Nuclear with expertise in the Health Physics area, a Board Certified Health Physicist.
The inspector informed the Director, ANPP Standards and Technical Support that the proposed improvements look good provided they are implemented in a timely fashion.
The inspector added that methods for addressing short term interim actions following an event should be developed.
The Director acknowledged the inspectors concern.
Exit Interview The inspector met with the individuals denoted in paragraph 1 at the conclusion of the inspection periods ending on September 23, 2988, and October 7, 1988.
The scope and findings of the inspection were summarized.
The licensee was informed of'he apparent violations, discussed in paragraphs 2 and 3.
The inspector reiterated the concerns discussed in this report to the licensee's. staff.
The inspectors concerns were acknowledged by the Vice President, Nuclear Production.