EA-98-280 - Calvert Cliffs 1 & 2 (Baltimore Gas & Electric Company)

September 2, 1998

EA 98-280

Mr. Charles H. Cruse
Vice President - Nuclear Energy
Baltimore Gas and Electric Company (BGE)
Calvert Cliffs Nuclear Power Plant
1650 Calvert Cliffs Parkway
Lusby, Maryland 20657-4702

SUBJECT:

NOTICE OF VIOLATION AND PROPOSED IMPOSITION OF CIVIL PENALTY – $55,000 (NRC Inspection Report Nos. 50-317/98-05 and 50-318/98-05)

Dear Mr. Cruse:

This letter refers to the NRC inspection conducted at the Calvert Cliffs Nuclear Power Plant during the period April 20-24, May 11-14, and May 19-20, 1998, the findings of which were provided to you during exit meetings on April 24, May 14, and May 20, 1998. The inspection report was sent to you on June 2, 1998. During the inspection, several apparent violations were identified related to the failure to properly implement your radiological control procedures for activities in the reactor annulus on April 9, 1998. On June 18, 1998, a Predecisional Enforcement Conference was conducted with you and members of your staff, to discuss the violations, their causes, and your corrective actions.

Based on the information developed during the inspection, and the information provided during the enforcement conference, three violations of NRC requirements are being cited and are described in the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice). The violations, which involved multiple failures to adhere to your radiological control procedures during replacement of nuclear instrumentation (NI) detectors in the reactor annulus, included: (1) the failure of workers to wear alarming dosimetry when entering the reactor annulus; (2) the failure of radiation protection personnel to stop work when unexpected alarms and radiological conditions were encountered; and (3) the failure to properly determine worker stay times for work in a high radiation area.

The violations are associated with two instances, both of which occurred on April 9, 1998, wherein personnel failed to follow radiological control procedures for personnel monitoring. In the first instance, in the early morning hours of April 9, 1998, six workers entered the reactor vessel cavity to prepare for removal of insulation and replacement of the NI detectors. Four of these workers then entered the reactor annulus, a high radiation area (HRA) with accessible radiation dose rates that ranged from 2000 mR/hr to 6000 mR/hr. However, the individuals were not wearing alarming dosimetry as required by the special work permit (SWP). Although radiation safety personnel were required to physically verify that the workers were wearing the required dosimetry prior to entering the HRA, these checks were not adequately performed. The alarming dosimeters were apparently prepared for use by the lead radiation safety technician (RST); however, the dosimeters were not provided to the workers and use of the dosimeters was not discussed at the pre-job briefing.

In the second instance, later that morning, an instrumentation and controls (I&C) technician entered the reactor annulus to attempt to relatch a detector well. Although the I&C technician was provided with alarming teledosimetry as required by the SWP, the dose and dose rate alarms for three of the five detectors were not set properly in accordance with applicable procedures. The three incorrectly set detectors alarmed almost immediately when the worker entered the annulus area and continued to alarm until the worker left the area approximately nine minutes later. However, the RST assigned to monitor the teledosimetry data did not react to the alarms nor stop the work, as required, when unexpected alarms occurred as he was apparently focused on the observation of only one of the correctly set detectors. Furthermore, although one of the detectors encountered dose rates in excess of the SWP limit, the RST, who was in voice contact with the I&C technician, did not instruct the I&C technician to exit the area, as required, when unexpected radiological conditions are encountered. As a result, the I&C technician received an unplanned exposure of approximately 760 mR to the left thigh which was in excess of the SWP dose limit of 600 mR. In addition to the failures to wear the proper dosimetry and to properly monitor personnel exposure, the stay times for both HRA entries were calculated incorrectly, resulting in non-conservative estimates of the time available for the workers to remain in the HRA.

The failure to adhere to radiological control procedures for monitoring and controlling personnel exposure resulted in one worker receiving an unplanned exposure in excess of the SWP limit, and also created the potential for additional workers to receive unplanned exposures. Multiple barriers for control of personnel exposure failed or were ineffective, including procedural controls, training, and management oversight. These failures represent a significant lack of attention toward control of radiological activities, in particular the control of personnel exposure. Therefore, the violations in this Notice are of significant concern and are classified in the aggregate as a Severity Level III problem in accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions " (Enforcement Policy), NUREG-1600.

The NRC is particularly concerned that these failures involve recurrence of the some of the same fundamental problems in your radiological protection program that caused a serious event in April 1997, in which you failed to implement appropriate radiological controls during diving operations in the Unit 2 spent fuel pool. A $176,000 civil penalty was previously issued to you for the related violations that were categorized at Severity Level II. A Severity Level III NOV without a civil penalty was also issued for your failure to establish adequate controls for airborne radioactivity for work in the reactor cavity in May 1997. Although a civil penalty could have been considered for the Severity Level III problem, discretion was exercised not to propose a civil penalty because the violations related to the cavity event occurred approximately one month after the diver event and appeared to be the result of the same fundamental performance deficiencies. During the April 9, 1998, entries to the annulus, deficiencies similar to those identified during the 1997 events were identified, including ineffective pre-job briefings, failure of radiation protection personnel to provide adequate monitoring of personnel exposure, and ineffective management oversight. As you explained at the conference, your corrective actions following the diver event were focused on improving the preparation and planning of radiological control activities. However, you failed to recognize that behavioral changes were needed, and you did not follow through with the implementation of those necessary controls. Although you established and communicated your expectations for the safe conduct of work in radiologically controlled areas, it appears that the plant staff, including radiation safety personnel, had not fully embraced or internalized these standards.

In accordance with the Enforcement Policy, a base civil penalty in the amount of $55,000 is considered for a Severity Level III problem. Since Calvert Cliffs has been the subject of escalated enforcement actions within the last 2 years⁽¹⁾, the NRC would normally consider whether credit was warranted for Identification and Corrective Action in accordance with the civil penalty assessment process in Section VI.B.2 of the Enforcement Policy. Although another RST technician recognized the alarms upon completion of work in the annulus area, the unplanned exposure to the I&C technician occurred due to the failure of the assigned RST to respond to the conditions that were clearly indicated by the alarms and teledosimetry data. Following the identification of the unplanned exposure, you took appropriate actions to stop work in the Unit 1 reactor annulus and perform an investigation of the event and assessment of your radiological control activities. As a result of this investigation, you identified the failure to wear alarming dosimetry in the early morning hours of April 9, 1998, and the incorrect stay time calculations. Your corrective actions which include: (1) providing increased management involvement and supervisory oversight of pre-job planning, pre-job briefing, and actual work activities; (2) plans to update the Radiation Protection Improvement Plan (RPIP) with lessons learned from these events; and (3) plans to standardize radiation protection work practices and improve procedures for work in the RCA appear to be comprehensive.

Notwithstanding these actions, your performance in the last year in the area of radiological controls has been particularly poor as evidenced by the diver event in April 1997, the failure to establish adequate controls for airborne radioactivity for work in the reactor cavity in May 1997, and the events associated with replacement of NI detectors in the reactor annulus in April 1998. These three cases each had similar root causes and demonstrate a lack of regard for the importance of radiation protection by a number of your personnel. The implementation of your corrective actions for the 1997 events, which included an assessment of all aspects of your radiation safety program and which should have precluded the 1998 violations, were ineffective. Therefore, I have decided, in light of your previous performance and your failure to preclude recurrence of these violations, to propose a civil penalty at the base amount in accordance with Section VII.A.1(c) and (d) of the Enforcement Policy.

Accordingly, to emphasize the importance of appropriate management oversight and control of radiation protection activities and the need for ensuring that your corrective actions are effectively implemented, I have been authorized, after consultation with the Director, Office of Enforcement, and the Deputy Executive Director for Regulatory Effectiveness, to issue the enclosed Notice of Violation and Proposed Imposition of Civil Penalty (Notice) in the amount of $55,000 for the violations.

You are required to respond to this letter and should follow the instructions specified in the enclosed Notice when preparing your response. As noted above, your corrective actions do appear to be comprehensive. However, you had previously described corrective actions that were thought to be comprehensive. In light of this being your third radiation protection incident within a year, your response should address why you have confidence that your corrective actions this time will effectively preclude similar events in the future. Failure to achieve effective lasting corrective action may result in more significant enforcement action. The NRC will use your response, in part, to determine whether further enforcement action is necessary to ensure compliance with regulatory requirements.

In accordance with 10 CFR 2.790 of the NRC's "Rules of Practice," a copy of this letter, its enclosure, and your response will be placed in the NRC Public Document Room (PDR).

		Sincerely,
		ORIGINAL SIGNED BY WILLIAM L. AXELSON
	FOR	Hubert J. Miller Regional Administrator

Docket/License Nos: 50-317/DPR-53
                                   50-318/DPR-69

Enclosure: Notice of Violation and Proposed Imposition of Civil Penalty

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ENCLOSURE

NOTICE OF VIOLATION

AND

PROPOSED IMPOSITION OF CIVIL PENALTY

Baltimore Gas & Electric Company Calvert Cliffs

Docket Nos. 50-317; 50-318 License Nos. DPR-53; DPR-69 EA 98-280

During an NRC inspection conducted during the period April 20-24, May 11-14, and May 19-20, 1998, violations of NRC requirements were identified. In accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," NUREG-1600, the NRC proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C. 2282, and 10 CFR 2.205. The particular violations and associated civil penalty are set forth below:

	Technical Specification 6.4, Procedures, (Amendment No. 216) requires in Section 6.4.1 that written procedures shall be established, implemented and maintained covering, among other matters the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2, dated February 1978. Regulatory Guide 1.33, Revision 2, recommends in Section e. of Appendix A that radiation protection procedures be established including procedures for access control, radiation surveys, radiation permit system, and personnel monitoring.
	Administrative Procedure RP-1-100, Revision 1, "Radiation Protection," implements requirements for radiation protection. Section 5.2.E of RP-1-100 requires personnel assigned to perform a job in a radiologically controlled area (RCA) to comply with the requirements of the special work permit (SWP) at all times.
	Radiation Protection Procedures RSP 1-132, Revision 1, "Job Coverage In Radiological Controlled Areas," RSP 1-129, Revision 2, "Operation of the SAIC Remote Monitoring System," and RSP 1-124, Revision 2, "Operation of the ALNOR System," provide requirements and responsibilities for radiation safety personnel for access control, radiation surveys, and personnel monitoring.
	Section 6.1.C. of RSP 1-132 requires that if entry into a high radiation area is to occur, the licensee shall verify, prior to worker entry, that each worker is in compliance with Attachment 1 to the procedure (High Radiation Area Pre-Entry Checklist). Item 1 of the checklist requires that radiation safety personnel are to physically verify that the worker is wearing their dosimetry per the applicable requirements.
	Section 6.1.F of RSP 1-132 requires radiation protection personnel to perform SWP requirements and monitor radiological conditions and worker's dose. Licensees are required to control the occupational dose to individuals to an annual limit which is more limiting of specified exposures, including the total dose equivalent, the deep-dose equivalent and exposures to the extremities (10 CFR part 20.1201(a)). The total dose equivalent is the sum of the deep-dose equivalent (for external exposures) and committed effective dose equivalent (for internal exposures). The deep-dose equivalent applies to external whole-body exposure. Whole body means, the head, trunk arms above the elbow and legs above the knee (10 CFR part 20.1003). Each licensee shall monitor exposures to radiation and radioactive material at levels sufficient to demonstrate compliance with the occupational dose limits (10 CFR Part 20.1501).
	Section 6.1.F.4 of RSP 1-132 requires that, if stay times are used for dose control, then the licensee shall monitor dose, dose rates, and stay times per the SWP. Section 6.1.F.5 of RSP 1-132 requires that, if any unexpected alarms or radiological conditions are encountered, the licensee shall stop and instruct personnel to exit the area.
	Section 6.2 of RSP 1-129 requires that the PD(E)-4 (mobile transceiving gamma dose and dose rate meter) operating parameters be set per Attachment 3 thereto. Attachment 3 requires, in part, that the dose and dose rate alarms be set at the SWP limits. Section 6.3 of RSP 1-129 requires that the applicable information specified on Attachment 5, thereto is to be recorded on Attachment 5 or a similar form when a PD(E)-4 is issued. The applicable information includes detector serial number, location, dose alarm, and dose rate alarm.
	Section 6.4.K of RSP 1-124 requires that the issuance of a RAD-100 dosimeter (ALNOR) be recorded on a form similar to Attachment 4, thereto, or on an approved computer database.
	SWP No. 1312, dated March 31, 1998, provided radiological information and requirements for replacement of nuclear instrumentation (NI) detectors. The SWP specified special dosimetry requirements for workers entering the reactor annulus, a locked high radiation area, and required alarming dosimetry for workers wearing special dosimetry. ALNORS were to be used if SAIC secondary dosimetry was not used. A dose limit of 600 mR and a dose rate limit of 8000 mR/hr were specified for work in the reactor annulus. The ALNOR dosimetry was to have its dose alarm at 510 millirem and its dose rate alarm set at 8000 mR/hr. SWP 1312 also required the coverage radiation safety technician (RST) to determine stay times for all workers entering High Radiation Areas and adjust based on conservative direct reading dosimetry readings .
	1.	Contrary to the above, on April 9, 1998, the requirements of RP-1-100, RSP 1-132, and RSP 1-124 were not implemented for an entry into the reactor annulus to remove insulation and prepare the NI detectors for removal and replacement, as evidenced by the following examples:
		The RST that entered the reactor annulus to perform surveys wore a RAD-100 dosimeter; however, issuance of the dosimeter was not recorded on a form or an approved computer database, as required by RSP 1-124.
		Four workers entered the reactor annulus but were not provided and did not wear SAIC alarming dosimetry or ALNOR alarming dosimeters, as required by SWP 1312.
		Radiation safety personnel did not adequately verify that the workers were wearing the dosimetry required by the SWP in that the Radiation Safety Technicians (RSTs) failed to identify that the workers entering the annulus were not wearing SAIC alarming dosimetry or ALNOR alarming dosimeters, as required by RSP 1-132. (01013)
	2.	Contrary to the above, on April 9, 1998, the requirements of RSP 1-129 and RSP 1-132 were not implemented for a subsequent entry into the reactor annulus to attempt to relatch a NI detector well, as evidenced by the following examples:
		Three of the five detector dose alarms on the PD(E)-4 dosimetry used by an I&C technician performing work in the reactor annulus were not set at the SWP dose limit of 600 mR and the dose rate limit of 8000 mR/hr, as required by SWP 1312. The three dose alarms were left at the calibration settings of 25 mR and 2780 mR/hr.
		A PD(E)-4 was issued to an I&C technician entering the annulus and the applicable information was not recorded on Attachment 5 or a similar form, as required by RSP 1-129.
		Radiation safety personnel failed to adequately monitor radiological conditions and worker's dose and did not stop the work and instruct personnel to exit the area when unexpected alarms and radiological conditions were encountered, as required by RSP 1-132. Specifically:
			-   RP personnel inadequately monitored a worker's dose, in that only one of five SAIC detectors on the technician was monitored in a real time mode and the dose provided by the monitored detector (chest) was not the highest integrated dose to any portion of the whole body. The highest integrated dose was at the thigh.
			-   Three of five SAIC detectors continuously alarmed, including the detector indicating the highest whole body dose location, upon the worker's entry into the annulus, and no action was taken in response to the alarms. The three alarms remained in alarm condition for the duration of the entry (approximately nine minutes).
			-    RP personnel took no action when one of the non-monitored detectors (left thigh) detected radiation dose rates in excess of the dose rate limit specified on the SWP. (01023)
	3.	Contrary to the above, on April 9, 1998, the requirement of SWP 1312, to determine stay times for workers entering high radiation areas, was not implemented by the coverage RST, as evidenced by the following examples:
		The stay time determined for the workers entering the annulus to remove insulation and prepare the NI detectors for removal and replacement was incorrect. The coverage RST incorrectly assumed a stay time of 9 minutes which was determined based on the time to accumulate 600 mR in a 4000 mR/hr radiation field. However, as specified in SWP 1312 the stay time should have been determined based on the ALNOR dose alarm set point of 510 mR to preclude workers from exceeding the SWP 600 mR dose limit. The correct stay time was 7.6 minutes.
		The stay time determined for the workers entering the annulus to attempt to relatch a NI detector well was incorrect. The stay time of 10 minutes used by the coverage RST was incorrect. The stay time was determined based on the time to accumulate 600 mR in a 6000 mR/hr radiation field. The correct stay time was 6 minutes. (01033)
	These violations are classified in the aggregate as a Severity Level III problem (Supplement IV). Civil Penalty - $55,000

Pursuant to the provisions of 10 CFR 2.201, Baltimore Gas and Electric Company (Licensee) is hereby required to submit a written statement or explanation to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, within 30 days of the date of this Notice of Violation and Proposed Imposition of Civil Penalty (Notice). This reply should be clearly marked as a "Reply to a Notice of Violation" and should include for each alleged violation: (1) admission or denial of the alleged violation, (2) the reasons for the violation if admitted, and if denied, the reasons why, (3) the corrective steps that have been taken and the results achieved, (4) the corrective steps that will be taken to avoid further violations, and (5) the date when full compliance will be achieved. If an adequate reply is not received within the time specified in this Notice, an Order or a Demand for Information may be issued as why the license should not be modified, suspended, or revoked or why such other action as may be proper should not be taken. Consideration may be given to extending the response time for good cause shown. Under the authority of Section 182 of the Act, 42 U.S.C. 2232, this response shall be submitted under oath or affirmation.

Within the same time as provided for the response required above under 10 CFR 2.201, the Licensee may pay the civil penalty by letter addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, with a check, draft, money order, or electronic transfer payable to the Treasurer of the United States in the amount of the civil penalty proposed above, or the cumulative amount of the civil penalties if more than one civil penalty is proposed, or may protest imposition of the civil penalty in whole or in part, by a written answer addressed to the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission. Should the Licensee fail to answer within the time specified, an order imposing the civil penalty will be issued. Should the Licensee elect to file an answer in accordance with 10 CFR 2.205 protesting the civil penalty, in whole or in part, such answer should be clearly marked as an "Answer to a Notice of Violation" and may: (1) deny the violation(s) listed in this Notice, in whole or in part, (2) demonstrate extenuating circumstances, (3) show error in this Notice, or (4) show other reasons why the penalty should not be imposed. In addition to protesting the civil penalty in whole or in part, such answer may request remission or mitigation of the penalty.

In requesting mitigation of the proposed penalty, the factors addressed in Section VI.B.2 of the Enforcement Policy should be addressed. Any written answer in accordance with 10 CFR 2.205 should be set forth separately from the statement or explanation in reply pursuant to 10 CFR 2.201, but may incorporate parts of the 10 CFR 2.201 reply by specific reference (e.g., citing page and paragraph numbers) to avoid repetition. The attention of the Licensee is directed to the other provisions of 10 CFR 2.205, regarding the procedure for imposing a civil penalty.

Upon failure to pay any civil penalty due which subsequently has been determined in accordance with the applicable provisions of 10 CFR 2.205, this matter may be referred to the Attorney General, and the penalty, unless compromised, remitted, or mitigated, may be collected by civil action pursuant to Section 234c of the Act, 42 U.S.C. 2282c.

The response noted above (Reply to Notice of Violation, letter with payment of civil penalty, and Answer to a Notice of Violation) should be addressed to: James Lieberman, Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, One White Flint North, 11555 Rockville Pike, Rockville, MD 20852-2738, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region I, and a copy to the NRC Resident Inspector at the facility that is the subject of this Notice.

Because your response will be placed in the NRC Public Document Room (PDR), to the extent possible, it should not include any personal privacy, proprietary, or safeguards information so that it can be placed in the PDR without redaction. If personal privacy or proprietary information is necessary to provide an acceptable response, then please provide a bracketed copy of your response that identifies the information that should be protected and a redacted copy of your response that deletes such information. If you request withholding of such material, you must specifically identify the portions of your response that you seek to have withheld and provide in detail the bases for your claim of withholding (e.g., explain why the disclosure of information will create an unwarranted invasion of personal privacy or provide the information required by 10 CFR 2.790(b) to support a request for withholding confidential commercial or financial information). If safeguards information is necessary to provide an acceptable response, please provide the level of protection described in 10 CFR 73.21.

Dated at King of Prussia, Pennsylvania
this Second day of September 1998

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¹e.g., A Notice of Violation and Proposed Imposition of Civil Penalties in the amount of $176,000 was issued on August 11, 1997 (EA 97-192) and a Notice of Violation without a civil penalty was issued on March 20, 1998 (EA 98-106). Both of these actions involved deficient radiological controls during the 1997 Unit 2 refueling outage.