United States Nuclear Regulatory Commission - Protecting People and the Environment

Information Notice No. 86-44: Failure to Follow Procedures When Working in High Radiation Areas

                                                          SSINS No.:  6835 
                                                          IN 86-44         

                                UNITED STATES
                        NUCLEAR REGULATORY COMMISSION
                    OFFICE OF INSPECTION AND ENFORCEMENT
                           WASHINGTON, D.C. 20555

                                June 10, 1986

Information Notice No. 86-44:   FAILURE TO FOLLOW PROCEDURES WHEN WORKING
                                   IN HIGH RADIATION AREAS 

Addressees: 

All nuclear power reactor facilities holding an operating license (OL) or a
construction permit (CP) and research and test reactors.

Purpose: 

This information notice is provided to alert licensees of the problem of
recurring, unauthorized entries by maintenance workers into high radiation
areas. A recent event is discussed below, and a related event is summarized
in Attachment 1. Since the workers ignored and bypassed maintenance
procedures that include radiological controls established to limit exposures
in high radiation areas, it is fortuitous that during these entries no
personnel exposure limits were exceeded.

It is expected that recipients will review this notice for applicability to
their facilities' work controls programs and consider actions, if
appropriate, to preclude the occurrence of a similar problem at their
facilities. Suggestions contained in this information notice do not
constitute NRC requirements and, therefore, no specific action or written
response is required.

Past Related Correspondence: 

INPO Significant Event Report (SER) 50-85, "Uncontrolled Personnel Radiation
  Exposure," November 4, 1985 (discusses two events).

INPO Significant Operating Experience Report (SOER) 85-3, "Excessive
  Personnel Radiation Exposures," April 30, 1985 (discusses seven events).

Information Notice No. 84-19, "Two Events Involving Unauthorized Entries
  Into PWR Reactor Cavities," March 21, 1984.

Information Notice No. 84-59, "Deliberate Circumventing of Station Health
  Physics Procedures," August 6, 1984 (discusses six events).





8606040010 
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                                                            IN 86-44  
                                                            June 10, 1986  
                                                            Page 2 of 3 

Description of Circumstances:

On January 8, 1986, at Turkey Point, an instrument and controls (IC)
technician made an unaccompanied, unauthorized entry into a high radiation
area to complete repairs on the traversing incore probe (TIP) drive unit with
an irradiated TIP withdrawn into the work area. Earlier that same day, with
a health physics (HP) technician providing job coverage, the IC technician
had made adjustments to the TIP drive unit (dose rates only 5 to 25 mR/hr),
which later enabled the technician to successfully withdraw the TIP into the
accessible TIP drive work area.

During the unauthorized entry, the IC technician received 500 millirem whole
body exposure during an approximately 5-minute stay time in a work area,
which was later calculated to be 6 R/hr in the general area. The radiation
level 1 foot away from the work area was 65-70 R/hr on contact with the
tubing containing the irradiated TIP. The low-range Geiger-Mueller (GM)
portable survey instrument (scale of 0-1 R/hr) used by the IC technician upon
entering the high radiation area initially moved up the scale to 800 mR/hr
and then reportedly went rapidly down the scale to zero, when moved closer
to the radiation source. The IC technician failed to recognize the
malfunctioning survey instrument and stayed in the area to complete his
maintenance task. At these dose rates, it was fortuitous that the technician
did not remain in the TIP area for any longer period.

Subsequent licensee and NRC regional review of the event revealed several
key factors that contributed to the incident.

1.   Failure To Follow Procedures 

     Numerous procedural violations occurred before and during the
     unauthorized entry. These violations included failure to notify HP
     personnel before operating the TIP, performing craft work outside the
     scope of the authorized plant work order (PWO), and making entry and
     working alone on the TIP system.

2.   Personnel Shortcomings 

     The IC technician's foreman failed to clearly define the TIP system
     problem and provide adequate instructions on the PWO. The IC technician
     failed to obey the local radiological area warning, a posting that read
     "high radiation area - keep out." Inadequate training caused the IC
     technician to fail to recognize a malfunctioning survey instrument
     (downscale reading caused by GM detector tube continuous discharge
     response to intense radiation levels), which he was using to help
     control his exposure.

The NRC noted subsequent to the event that, although not contributory to this
incident, governing maintenance procedures for the TIP system did not require
tagging out of other operable TIPs (to prevent inadvertent withdrawal into
an occupied work area) with work in progress on a malfunctioning TIP unit.
For future TIP work, the licensee agreed to control movement of the
irradiated TIPs with equipment tag out controls.

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                                                            IN 86-44
                                                            June 10, 1986
                                                            Page 3 of 3

Discussion: 

The NRC continues to note repeated occurrences of unauthorized entries into
high radiation areas (see Past Related Correspondence). In most of the
individual events discussed in these documents and the two events in this
notice, failure of personnel to adhere to existing work/control procedures
or radiation work permits (RWP), or both, is a central cause of the exposure
incidents. Adherence to work/surveillance procedures forms a basic framework
for providing effective, consistent radiological controls for work in high
radiation areas. Short of providing direct, continuous health physics
coverage for each and every task, these procedures serve as the formal
mechanism for initiating necessary communications between various plant
worker crafts groups and the health physics support group. This communication
results in appropriate radiological support (e.g., RWP issuance) for the
maintenance/surveillance activities. Bypassing these procedures and thus
failing to comply with the radiological precautions in them seriously weakens
the health physics control program established to protect the workers. It is
the licensee's responsibility to ensure that these procedures are adhered to.

To emphasize the importance of workers properly performing work activities
in high radiation areas, appropriate enforcement action has been proposed for
the Turkey Point event (proposed $50,000 civil penalty).

No specific action or written response is required by this information
notice. If you have any questions about this matter, please contact the
Regional Administrator of the appropriate regional office or this office.


                                   Edward L. Jordan, Director 
                                   Division of Emergency Preparedness 
                                     and Engineering Response 
                                   Office of Inspection and Enforcement 

Technical Contacts: James E. Wigginton, IE 
                    (301) 492-4967 

                    Roger L. Pedersen, IE 
                    (301) 492-9425 

Attachments: 
1.   Related Exposure Event 
2.   List of Recently Issued IE Information Notices  

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                                                            Attachment 1   
                                                            IN 86-44       
                                                            June 10, 1986  
                                                            Page 1 of 1    

RELATED EVENT SUMMARY 

At the Cooper Nuclear Station on August 28, 1985, two IC technicians
performed maintenance (TIP alignment) as required by a craft work procedure.
Contrary to the work procedure's radiological-cautions warnings, these
workers failed to obtain a special RWP and entered the TIP drive enclosure
housing, ignoring the access posting, "Notify Health Physics Prior to
Opening." The TIP maintenance procedure further warned that the drive unit's
Gleason reel is spring loaded and the incore detector could be withdrawn by
the spring tension. It further warned that the withdrawn incore detector
probe could be highly radioactive. 

Upon opening the unsurveyed enclosure, they found the TIP had withdrawn into
the enclosure and the detector had broken off. The technicians immediately
exited the high radiation and high airborne radioactivity area. The
individuals each received approximately 200 mrem whole body exposure and
airborne intakes of 44 and 90 MPC-hrs.

As corrective actions, the licensee (1) stressed to all station personnel the
importance of properly following radiological controls and (2) revised the
governing maintenance procedure to require written documentation (signoff)
notifying HP before working on the TIP system.
Page Last Reviewed/Updated Tuesday, November 12, 2013